Emergency department presentations in Tasmania, Australia : a sequential explanatory investigation

\\(Introduction\\) The problem of increasing numbers of patients presenting to hospital emergency departments (EDs), contributing to crowding, has been labelled an international crisis. Consequences for patients who present to crowded EDs can include delays in receiving required medications, such as analgesics and antibiotics, and poorer patient outcomes, including increased inpatient mortality. Similarly, there are negative impacts for staff who work in crowded EDs, including an increased risk of experiencing violence in the workplace, increased workplace stress, and the reduced capacity to adhere to recommended treatment guidelines. In terms of the impact of ED crowding on the healthcare system itself, there is an identified correlation between ED length of stay and inpatient length of stay, albeit without a direct causative link being established. Many strategies and policy initiatives have been suggested and implemented to combat ED crowding. These have focussed on ED demand management, timelier ED throughput times, and strategies to combat access block (i.e. the inability to transfer patients from the ED once immediate treatment is complete). Nevertheless, ED crowding continues to be one of the biggest issues facing healthcare systems worldwide. Australia experienced a 37% increase in demand for ED services in the ten years from 2000-01 to 2009-10, with the greatest reported increase (73%) being in Tasmania. A 2014 report on the delivery of health services in Tasmania, commissioned by the Australian government, noted that there were high rates of ED access block and 'general practice-type' presentations in Tasmanian EDs, and suggested that this required urgent attention. The report highlighted that ED crowding was a key issue facing the state's healthcare system. Noting regional variations in ED growth across the state and recognising that ED presentations impacted significantly on the health care of Tasmanians, the Tasmanian government recommended that sources of ED presentations be analysed so that government decisions about the design and delivery of emergency care could ensure that patients continued to receive high quality care into the future. Recognising that ED crowding is an issue internationally, nationally and in Tasmania, the aim of this research project was to examine temporal and regional patterns in hospital ED presentations in Tasmania, and subsequently investigate the factors driving ED usage. \\(Method\\) A systematic review of the international scientific literature investigating the causes, consequences and solutions to ED crowding was initially undertaken. The study subsequently utilised a multiphase, emergent mixed method, quantitative-dominant, explanatory sequential design. Phase one involved a retrospective data analysis of four years (2010-11 to 2013-14) of ED presentations across the state of Tasmania to identify longitudinal patterns of ED usage by the state's residents. Phase two involved a retrospective data analysis of six years (2010-11 to 2015-16) of inpatient data at one Tasmanian hospital to investigate the hypothesis that patient-perceived access to care, as measured by potentially preventable hospitalisations (PPHs), was one driver of ED presentations and subsequent hospitalisations in the elderly. Phase three involved an audit of the digital medical records (DMRs) of patients aged ‚Äöv¢‚Ä¢ 75 years who had experienced a short-stay admission (length of stay ‚Äöv¢¬ß 2 days) for congestive cardiac failure (CCF) in the years 2010-11 and 2015-16, at the same hospital, in an attempt to ascertain the reasons behind an increase in these specific types of admissions over the six-year period. From the results from the first three quantitative phases, a profile was developed of the types of patients identified as contributing to increased ED presentations in the state (e.g. patients aged ‚Äöv¢‚Ä¢ 75 years who had experienced a short-stay admission for CCF). In phase four, this profile was used to prospectively recruit participants and, using semi-structured interviews, qualitatively explore the role of patient-perceived access to care in ED presentations and subsequent PPHs in Tasmania. \\(Results\\) The systematic review illustrated that the negative consequences of ED crowding are well established, as well as highlighting a dearth in the academic literature of studies investigating the specific causes of crowding. Nationally and internationally, many solutions to crowding have been suggested, trialled and modelled, with varying levels of success. However, it was clear from the literature that the causes of ED crowding are not well understood and likely to be contextually specific to the environment in which the crowding is taking place. Consequently, implemented solutions are unlikely to have a sustained impact if they are not addressing the specific causes of crowding in that environment. ED presentations by elderly patients with chronic and complex conditions emerged as a relatively new driver of crowding. Key results from each phase of the study were: Phase 1: Research question/s What are the longitudinal patterns of ED presentations in Tasmania? Are there regional variations in patterns of ED presentations in Tasmania? Wide-ranging regional variations in patterns of ED presentations were evident across the state's three regions, including a 16% increase in ED presentations in the South, versus a 3.9% decrease in the North-West over four years. There was a significant per capita increase in ED presentations in the South of the state by those aged ‚Äöv¢‚Ä¢ 75 years, increasing at a mean rate of 12.5 per 1,000 residents per annum (95% CI 5.8 ‚Äö- 19.2). Phase 2: Research question What role do potentially avoidable admissions play in ED presentations in Tasmania? The rates of PPHs increased by 21% over six years, compared with a 1.7% increase in non-PPHs; per capita PPHs by those aged ‚Äöv¢‚Ä¢ 75 years increased by 10%. Short-stay admissions for PPHs accounted for 51% of all PPHs in patients aged ‚Äöv¢‚Ä¢ 75 years and increased by 70% over six years. CCF was the most common associated condition, accounting for 21% of all short-stay PPHs in the elderly and had increased by 174% over six years. Phase 3: Research question What are the patient and/or system factors driving the increase in ED presentations and short-stay hospital admissions for elderly patients with congestive cardiac failure in Tasmania? There was no appreciable difference over time in the profile of elderly patients who experienced an ED presentation and short-stay admission for CCF in the years 2010-11 and 2015-16; there was simply an increased volume of cases. The cohort in 2015-16 experienced 142 more ED presentations and 116 more hospital admissions compared to the cohort in 2010-11. A trend towards reducing length of stay even further (from 2 days to one day) was identified. Phase 4: Research question What role does patient-perceived access to care play in ED presentations and short-stay hospital admissions in Tasmania? Interview participants presented as articulate individuals who were keen to be involved in the management of their chronic condition. When viewed through the lens of the domains of access to care, the data analysis identified issues relating to a lack of person-centred care, particularly in the acute care setting, as well as an apparent lack of patient education enabling self-management of their chronic conditions. Poor continuity of care in the primary care setting and inadequate levels of health literacy were also identified as contributing to ED usage and hospital admission. \\(Discussion\\) Following the findings of the systematic review that the causes of crowding were not well articulated, a study was designed to identify local contextual issues driving ED presentations in Tasmania. This study identified a link between patient-perceived access to care, increased ED presentations and subsequent hospitalisations by the elderly. Tasmania has a population with a higher mean age than all other states and territories in Australia. All of the state is classified as either regional or remote, over one-third of its population lives in regions classified as being within the most socioeconomically disadvantaged quartile, and a higher proportion of its population suffers from chronic illness when compared to Australia as a whole. All of these factors have been shown to potentially contribute to increased ED utilisation. Therefore, understanding the difficulties faced by elderly people with chronic conditions in this region, particularly as regards gaining access to services to prevent and manage exacerbations of their chronic conditions, may enable better planning for the future health care needs of this growing patient demographic, not only locally, but nationally and internationally. \\(Conclusion\\) There is limited research and therefore understanding of the specific factors driving the increase in demand for ED care. However, it is clear that with increasing presentations and constrained health budgets, healthcare systems worldwide are struggling with the burden of increased ED presentations. While the drivers of ED utilisation are likely to be multi-factorial and contextually specific, findings of this research suggest that patient-perceived access to care plays a role. This is particularly true of elderly patients with chronic conditions. Results from this thesis suggest that clinicians, researchers and policy makers should focus their efforts on improving the health literacy of the population to support patient selfmanagement, as well as enhancing the availability of timely appointments with a regular primary care provider and providing genuine person-centred care.