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Emergency Medicine Australasia (2015) 27, 102–107
doi: 10.1111/1742-6723.12368
ORIGINAL RESEARCH
Age distribution of emergency department presentations in Victoria Gary L FREED,1 Sarah GAFFORINI2 and Norman CARSON3 1 Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia, 2Centre for Health Policy, The University of Melbourne, Melbourne, Victoria, Australia, and 3Victoria Department of Health, Melbourne, Victoria, Australia
Abstract Objectives: To describe patterns of ED utilisation over time, by patient age group and triage classification. Methods: Secondary analysis of data from all patients presenting to EDs in Victoria utilising the Victorian Emergency Minimum Dataset (VEMD) for the years 2002–2013. The VEMD includes all hospitals in Victoria with 24 h EDs. Results: The absolute number of presentations to EDs in Victoria has grown by over 52% in the last 11 years. The triage categories of highest urgency (1– 3) grew by 89% whereas the categories of lowest urgency (4–5) grew by 33%. Over this period, the 5 year age band with the greatest number of ED presentations has consistently been, by far, children 0–4 years of age. This age group has seen an increase of 29% in ED presentations overall with a >55% increase in Triage 1–3, and an increase of 16% in triage 4–5. For all age groups, there has been little change in the number of triage category 4–5 presentations since 2007/2008. However, for triage categories 1–3, there have been consistent increases in presentations across all age groups. Conclusion: The age range with the greatest absolute number of ED presentations in Victoria is children 0–4 years of age. This finding is consistent over time and across all
triage classifications. The age range with the second highest absolute number of ED presentations is comprised of those 20–24 years of age. This is in contrast to the frequent public attention placed on the volume of ED presentations by the elderly. Key words: adult, age, emergency department, paediatric, triage.
Introduction Access to care and increased volumes in hospital EDs has been an ongoing issue of concern in Australia. In the decade to 30 June 2009, presentations to EDs in metropolitan Melbourne increased by 55%.1 Increasing demand absent a corresponding increase in ED capacity can impact patient safety by contributing to overcrowding, longer waiting times and an increased risk of adverse events.2 In addition to concerns regarding safety, the satisfaction of Australians with their healthcare system might also be at risk. A number of reasons have been proposed for the increasing demand for ED services. These include an ageing population, increasing incidence of chronic illness and poor accessibility of general practice services.3 This latter aspect has led to a great deal of popular, political and academic interest in patients presenting at EDs who might safely be cared
Correspondence: Professor Gary L Freed, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Carlton, Melbourne, VIC 3053, Australia. Email: [email protected] Gary L Freed, MD, MPH, Professor; Sarah Gafforini, MS, Research Coordinator; Norman Carsons, MS, Data Analyst. Accepted 19 January 2015
Key findings • The age group with the greatest absolute number of ED presentations is children 0-4 years old. • The age group with the second highest absolute number of ED presentations are those 20-24 years old. • There has been a 52% increase in ED presentations overall in Victoria.
for elsewhere, particularly in primary care practices, thereby reducing demand for ED services. However, such patients are difficult to clearly categorise and definitively identify and there is no foolproof method to do so. Currently, all patients who present to EDs are classified on the Australasian Triage Scale (ATS) on a scale of 1 to 5 according to the urgency for which medical care is required. The most urgent patients receive a classification of 1 and those classified into categories 4 and 5 are considered to be of lower urgency. There has been significant attention in the media and the peer-reviewed literature regarding many aspects of the care provided in EDs, mostly focused on the adult and aged population. This might be due to an increasing focus on time-based targets in ED care and complexity of aged patients. However, there have been few studies that assess trends over time in the actual volume of ED care by patients of all ages and the ageadjusted rates of presentations across an entire state. Understanding not only the ages of patients that are experiencing growth in ED presentations, but importantly placing that growth in the
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context of the age groups where the bulk of the current volume of presentations occurs is essential to understand both current needs and to project future demand for services. The Victorian Emergency Minimum Dataset (VEMD) captures information for all ED presentations across the State of Victoria. Using these data from an 11 year period (2002–2013), the aim of the present study was to describe patterns of ED utilisation, paying particular attention to patient age group and urgency of presentation, as indicated by ATS category.
Methods Data were obtained for financial years 2002–2003 to 2004–2005, 2007– 2008 and 2010–2011 to 2012–2013 from the VEMD. 4 The VEMD includes de-identified demographic, and clinical data derived from presentations to all Victorian public hospitals with 24 h staffed EDs. Currently there are 38 hospitals providing data to the VEMD. Of these, six began to provide data in 2003, one in 2004 and one in 2011. The Data Collections Unit (DCU) of the Health Strategy Productivity and Analytics Division of the Victoria Department of Health manages VEMD operations. Data are collected at each reporting hospital and are transferred in a defined format to the DCU. An annually updated manual provides clinical, nursing and clerical staff with the necessary level of detail to accurately record patient demographics, diagnoses, procedures, injury surveillance and other data for reporting to the VEMD. Explanatory notes are included to promote consistent interpretation of the data items. All persons presenting at EDs are first ‘triaged’ or assessed for objective clinical urgency by a staff member (specifically trained and experienced) according to the five category ATS.5 In the present study we have grouped categories 4–5 (lowest urgency) to contrast with categories 1–3 (highest urgency). Presentation rates per 1000 persons (for each year of presentation and age group) were calculated as a ratio by taking the numerator as the number of presentations to ED (multiplied by
1000) obtained from VEMD, and the denominator as the estimated resident population (ERP) of Victorian residents in each age group obtained from the Australian Bureau of Statistics (ABS).6 Data were analysed using IBM SPSS Statistics Version 20 and Microsoft Office Excel 2003.
Results Absolute numbers of presentations The absolute number of presentations to EDs in Victoria has grown by over 52% in the past 11 years, from 947 238 in 2002/2003 to 1 448 171 in 2012/2013. Triage 1–3 presentations increased by 89% and triage 4–5 by 33%. The age distribution of ED presentations demonstrates a bimodal peak that is consistent over the years studied. Throughout this entire time period, the 5 year age band with the greatest number of ED presentations has consistently been, by far, children 0–4 years of age. This age group has seen an increase of 29% in ED presentations over this time period resulting in 161 988 presentations in 2012/2013. Triage 1–3 presentations in the 0–4 age group grew by 55% and triage 4–5 by 16%. The age band with the second highest volume of ED presentations, also consistently over time, has been those 20–24 years of age. This age band has had an increase of 49% over the same time period and had 112 127 ED presentations in 2012/
2013. Triage 1–3 presentations in the 20–24 age group grew by 95% and triage 4–5 by 32%. In contrast, the age band >65 years with the greatest number of presentations over this period is those 75–79 years. This age band experienced a growth of 45% and had 57 065 presentations in 2012/2013, with a 63% increase for triage 1–3 and a 27% increase for triage 4–5. When examined by triage category, the same age distribution patterns for the absolute numbers of ED presentations are maintained (Figs 1,2). For all age groups, there has been very little change in the number of triage category 4–5 presentations since 2007/ 2008. However, for triage categories 1–3, there have been consistent increases in the absolute numbers of presentations across all age groups.
Population based rates of ED presentations When ED presentations are examined in the context of rates per 1000 persons in specific age bands, a different pattern emerges (Figs 3,4). For triage category 4–5 presentations, rates are highest for the youngest and oldest age bands. Additionally, although similar patterns of these rates occur across all years of our study, population-based rates of such visits have not increased over time. In contrast, for triage category 1–3 presentations, the rates of presentation increase in a consistent pattern
Figure 1. Absolute numbers of ED presentations; triage categories 4 and 5. ( ), 2007/2008; ( ), 2010/2011; ( ), 2011/2012; ( 2003; ( 2013.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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Figure 2. Absolute numbers of ED presentations; triage categories 1–3. ( ), 2002/ ), 2007/2008; ( ), 2010/2011; ( ), 2011/2012; ( ), 2012/2013. 2003; (
that the majority of presentations for those in younger age groups are classified as triage category 4 or 5. After the 10–14 year age band, there is a consistent trend of decreasing proportion of category 4 or 5 presentations. Although this overall trend is consistent over time, triage 4–5 as a proportion of all ED presentations has also fallen for all age groups 64 years, highest in the earlier period up to 2007–2008 and then levelling off. This is consistent with another of our findings that, with increasing age, the proportion of presentations classified as higher urgency increase in a linear fashion beginning at age 25 and continuing thereafter. This trend was consistent over the study period with increasing proportions of visits in higher urgency conditions seen across all age groups. This finding likely reflects that the elderly indeed present with increasingly complex and urgent conditions or that there are aspects to their ED
utilisation patterns that might result in triage categorisation sometimes reflecting a lower urgency than would be appropriate to their clinical condition.2 One potential example would be those seniors for whom transportation to the ED is difficult to obtain and thus rely on ambulances.7–9 Such occurrences might occur more frequently in long-term care facilities where there is a paucity of GP care and even minor conditions prompt transport to the ED for evaluation and treatment.8–11 Without other mechanisms of transport available, ambulances may be utilised and result in a greater urgency in triage classifica-
tion. Further research into such circumstances should be conducted to better understand the root causes of elderly presentations to the ED prior to new policies and strategies being implemented, lest the resources expended not effectively target underlying causes of the problem.1 In the same vein, there has been much speculation regarding the reasons for the overall increased number of ED presentations over time. Some have postulated that problems with GP availability have played a role.2,12 However, objective data on actual same-day GP appointment availability for acute care are lacking in Australia. Perceptions of problems GP in availability are based on anecdote, professional opinion and calculations of GP to population ratios and have not been tested to determine their frequency or distribution across either urban or rural areas. Others have suggested that the gap amount charged over the Medicare rebate in some GP surgeries might be a financial barrier to care.13,14 Again, actual data on gap charges, their geographic distribution and prevalence are lacking. To date, information available to policymakers on the determinants of patient behaviour with regard to ED utilisation mostly has been anecdotal, conducted at single sites of patient care or based on expert opinion, not objective data.12,15 Such information will be helpful in creating policy options that address specifically the underlying causes of increases in ED presentations and can lead to evidence-based, rather than anecdote-based, policy decision. With specific regard to the volume of child presentations to the ED, some have opined that groups of parents might not have sufficient confidence in their GP to care for children, and thus are more likely to bring their child to the ED.12,15–17 Yet, there are limited data on such parental preferences and the reasons why they bring their children to the ED, especially for low urgency conditions. Such information would be helpful to policymakers and those responsible for the organisation and delivery of primary care services to develop strategies with the highest likelihood of success to address the volume of ED presentations for this population.
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Another possibility that might impact the volume of children presenting to EDs is the potential of GPs to refer children to the ED rather than care for them in their surgeries. Previous research has demonstrated that as the demography of Australia has changed, children comprise a progressively smaller proportion of both the general population and of GP visits.18 It is possible this might impact both the comfort of GPs in providing acute care to children, and their currency in paediatric care. Similarly, although there is increasing attention paid to improving the primary care management of chronic illnesses, almost all of the emphasis is placed on adults with conditions such as hypertension or diabetes. However, due to improvements in neonatal care and increased survival of children with other conditions, there are more children alive today with chronic illness than ever in Australia. Nevertheless, the number of extended consultations in primary care (those visits usually associated with the care of chronic or more complex conditions) for children has decreased in absolute numbers over the past two decades.19 It is unclear if these children comprise a significant proportion of ED visits. Future research is required address this issue. Previous studies have sought to determine whether some presentations to the ED categorised as low urgency might be able to addressed in GP offices.2,3,13,20–22 Others have sought to determine the expectations of the public with regard to ED utilisation and the appropriateness of their presentations to the ED.23–28 Limitations of the studies conducted within the last decade include the potential for selfjustification among those presenting to EDs and that all but one excluded children. Some studies were conducted at single EDs and therefore might not be generalisable. Our findings are consistent with those of Lowthian et al.1 but add several more years of recent data. Although we include population specific rates of ED presentations, we focus our results more on the absolute number of ED presentations by age group. Although we also found increased growth in ED presentations among the ageing community, the current volume of ED care
provided to patients at the other end of the age spectrum, across all triage categories, demands greater attention. The reasons for the magnitude of the presentations for children must be assessed to determine where models of care in the healthcare system need to be modified.
hospitals who have provided valuable perspectives to our work.
Author contributions All authors participated in the design of the research, the drafting and/or revision of the manuscript and approved the final product.
Limitations There were six hospitals added to the VEMD in 2003. These additions had an impact on the total number of presentations included in the VEMD subsequent to that year. However, this important caveat does not account for the entire increase in presentations observed. The VEMD is regularly assessed by an external advisory group for data integrity and completeness. The VEMD only contains data collected from EDs in Victoria. As such, our findings might or might not be applicable to other states.
Conclusions Whenever there is significant public attention focused on a topic regarding the health of a population, there is often a sense of urgency felt by policymakers and medical professionals to act expeditiously. Often such action is taken to address the ‘shrill voices’ in the public arena without the data necessary to develop true evidence-based policy options. Using data to drive policy options might take longer, but will result in a greater likelihood of successful action and a greater likelihood of responsible use of public funds. To meet the needs of Victorians, efforts should be made to ensure there is an adequate capacity and workforce within both the primary care as well as emergency services systems to provide care to patients, regardless of their age. The information provided from the present study should help in identifying from which age groups the volume of ED presentations emanate and thus prioritise specific areas for action.
Acknowledgements We thank the Emergency Physicians from both academic and community
Competing interests None declared.
References 1. Lowthian JA, Curtis AJ, Jolley DJ et al. Demand at the emergency department front door: 10-year trends in presentations. Med. J. Aust. 2012; 196: 128–32. 2. Lowthian JA, Smith C, Stoelwinder JU et al. Why older patients of lower clinical urgency choose to attend the emergency department. Intern. Med. J. 2013; 43: 59–65. 3. Nagree Y, Camarda VJ, Fatovich DM et al. Quantifying the proportion of general practice and low-acuity patients in the emergency department. Med. J. Aust. 2013; 198: 612– 5. 4. Victorian Department of Health. Health data standards and systems. Victorian Emergency Minimum Dataset (VEMD). 2014. [Accessed Jul 2014.] Available from URL: http:// www.health.vic.gov.au/hdss/vemd/ index.htm 5. Australian College For Emergency Medicine. Guidelines on the implementation of the Australasian Triage Scale in Emergency Department. Document No. G24, Approved 00 Nov, Last revised 13 Nov, Version No. 03. 2013. 6. Australian Bureau of Statistics. Population by age and sex, regions of Australia 2012. ABS Cat. No. 3235.0. 2013. 7. Codde J, Frankel J, Arendts G et al. Quantification of the proportion of transfers from residential aged care facilities to the emergency department that could be avoided through improved primary care services. Australas. J. Ageing 2010; 29: 167– 71.
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8. Finn JC, Flicker L, Mackenzie E et al. Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia. Med. J. Aust. 2006; 184: 432–5. 9. Ting JY, Chang AM. Path analysis modeling indicates free transport increases ambulance use for minor indications. Prehosp. Emerg. Care 2006; 10: 476–81. 10. Arendts G, Reibel T, Codde J et al. Can transfers from residential aged care facilities to the emergency department be avoided through improved primary care services? Data from qualitative interviews. Australas. J. Ageing 2010; 29: 61–5. 11. Codde J, Arendts G, Frankel J et al. Transfers from residential aged care facilities to the emergency department are reduced through improved primary care services: an intervention study. Australas. J. Ageing 2010; 29: 150–4. 12. Williams A, O’Rourke P, Keough S. Making choices: why parents present to the emergency department for nonurgent care. Arch. Dis. Child. 2009; 94: 817–20. 13. Siminski P, Bezzina AJ, Lago LP et al. Primary care presentations at emergency departments: rates and reasons by age and sex. Aust. Health Rev. 2008; 32: 700–9. 14. Masso M, Bezzina AJ, Siminski P et al. Why patients attend emergency departments for conditions potentially appropriate for primary care:
15.
16.
17.
18.
19.
20.
21.
reasons given by patients and clinicians differ. Emerg. Med. Australas. 2007; 19: 333–40. Ryan M, Spicer M, Hyett C et al. Non-urgent presentations to a paediatric emergency department: parental behaviours, expectations and outcomes. Emerg. Med. Australas. 2005; 17: 457–62. Cooper C, Simpson JM, Hanson R. The district hospital emergency department: why do parents present? Emerg. Med. 2003; 9: 68–70. Woolfenden S, Ritchie J, Talbot-Stern J et al. Parental use of a paediatric emergency department as an ambulatory care service. Aust. N. Z. J. Public Health 2000; 24: 204–6. Freed GL, Sewell J, Spike N et al. Changes in the demography of Australia and therefore general practice patient populations. Aust. Fam. Physician 2012; 41: 715–9. Freed GL, Spike NA, Sewell JR et al. Changes in longer consultations for children in general practice. J. Paediatr. Child Health 2013; 49: 325–9. Ng JY, Fatovich DM, Turner VF et al. Appropriateness of healthdirect referrals to the emergency department compared with self-referrals and GP referrals. Med. J. Aust. 2012; 197: 498–502. Bezzina AJ, Smith PB, Cromwell D et al. Primary care patients in the emergency department: who are they? A review of the definition of the ‘primary care patient’ in the emer-
22.
23.
24.
25.
26.
27.
28.
gency department. Emerg. Med. Australas. 2005; 17: 472–9. Sprivulis P. Estimation of the general practice workload of a metropolitan teaching hospital emergency department. Emerg. Med. 2003; 15: 32–7. Toloo GS, FitzGerald GJ, Aitken PJ et al. Ambulance use is associated with higher self-rated illness seriousness: user attitudes and perceptions. Acad. Emerg. Med. 2013; 20: 576– 83. Morgans A, Burgess S. Judging a patient’s decision to seek emergency healthcare: clues for managing increasing patient demand. Aust. Health Rev. 2012; 36: 110–4. Morgans A, Burgess SJ. What is a health emergency? The difference in definition and understanding between patients and health professionals. Aust. Health Rev. 2011; 35: 248–9. Callen JL, Blundell L, Prgomet M. Emergency department use in a rural Australian setting: are the factors prompting attendance appropriate? Aust. Health Rev. 2008; 34: 710– 20. Abernethie L, Nagree Y. Increased emergency department attendance: a qualitative investigation of health seeking behaviours. Just Policy 2004; 33: 6–16. Liaw ST, Hill T, Bryce H et al. Emergency and primary care at Melbourne hospital: reasons for attendance and satisfaction. Aust. Health Rev. 2001; 24: 120–34.
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Emergency Medicine Australasia (2015) 27, 102–107
doi: 10.1111/1742-6723.12368
ORIGINAL RESEARCH
Age distribution of emergency department presentations in Victoria Gary L FREED,1 Sarah GAFFORINI2 and Norman CARSON3 1 Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia, 2Centre for Health Policy, The University of Melbourne, Melbourne, Victoria, Australia, and 3Victoria Department of Health, Melbourne, Victoria, Australia
Abstract Objectives: To describe patterns of ED utilisation over time, by patient age group and triage classification. Methods: Secondary analysis of data from all patients presenting to EDs in Victoria utilising the Victorian Emergency Minimum Dataset (VEMD) for the years 2002–2013. The VEMD includes all hospitals in Victoria with 24 h EDs. Results: The absolute number of presentations to EDs in Victoria has grown by over 52% in the last 11 years. The triage categories of highest urgency (1– 3) grew by 89% whereas the categories of lowest urgency (4–5) grew by 33%. Over this period, the 5 year age band with the greatest number of ED presentations has consistently been, by far, children 0–4 years of age. This age group has seen an increase of 29% in ED presentations overall with a >55% increase in Triage 1–3, and an increase of 16% in triage 4–5. For all age groups, there has been little change in the number of triage category 4–5 presentations since 2007/2008. However, for triage categories 1–3, there have been consistent increases in presentations across all age groups. Conclusion: The age range with the greatest absolute number of ED presentations in Victoria is children 0–4 years of age. This finding is consistent over time and across all
triage classifications. The age range with the second highest absolute number of ED presentations is comprised of those 20–24 years of age. This is in contrast to the frequent public attention placed on the volume of ED presentations by the elderly. Key words: adult, age, emergency department, paediatric, triage.
Introduction Access to care and increased volumes in hospital EDs has been an ongoing issue of concern in Australia. In the decade to 30 June 2009, presentations to EDs in metropolitan Melbourne increased by 55%.1 Increasing demand absent a corresponding increase in ED capacity can impact patient safety by contributing to overcrowding, longer waiting times and an increased risk of adverse events.2 In addition to concerns regarding safety, the satisfaction of Australians with their healthcare system might also be at risk. A number of reasons have been proposed for the increasing demand for ED services. These include an ageing population, increasing incidence of chronic illness and poor accessibility of general practice services.3 This latter aspect has led to a great deal of popular, political and academic interest in patients presenting at EDs who might safely be cared
Correspondence: Professor Gary L Freed, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Carlton, Melbourne, VIC 3053, Australia. Email: [email protected] Gary L Freed, MD, MPH, Professor; Sarah Gafforini, MS, Research Coordinator; Norman Carsons, MS, Data Analyst. Accepted 19 January 2015
Key findings • The age group with the greatest absolute number of ED presentations is children 0-4 years old. • The age group with the second highest absolute number of ED presentations are those 20-24 years old. • There has been a 52% increase in ED presentations overall in Victoria.
for elsewhere, particularly in primary care practices, thereby reducing demand for ED services. However, such patients are difficult to clearly categorise and definitively identify and there is no foolproof method to do so. Currently, all patients who present to EDs are classified on the Australasian Triage Scale (ATS) on a scale of 1 to 5 according to the urgency for which medical care is required. The most urgent patients receive a classification of 1 and those classified into categories 4 and 5 are considered to be of lower urgency. There has been significant attention in the media and the peer-reviewed literature regarding many aspects of the care provided in EDs, mostly focused on the adult and aged population. This might be due to an increasing focus on time-based targets in ED care and complexity of aged patients. However, there have been few studies that assess trends over time in the actual volume of ED care by patients of all ages and the ageadjusted rates of presentations across an entire state. Understanding not only the ages of patients that are experiencing growth in ED presentations, but importantly placing that growth in the
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context of the age groups where the bulk of the current volume of presentations occurs is essential to understand both current needs and to project future demand for services. The Victorian Emergency Minimum Dataset (VEMD) captures information for all ED presentations across the State of Victoria. Using these data from an 11 year period (2002–2013), the aim of the present study was to describe patterns of ED utilisation, paying particular attention to patient age group and urgency of presentation, as indicated by ATS category.
Methods Data were obtained for financial years 2002–2003 to 2004–2005, 2007– 2008 and 2010–2011 to 2012–2013 from the VEMD. 4 The VEMD includes de-identified demographic, and clinical data derived from presentations to all Victorian public hospitals with 24 h staffed EDs. Currently there are 38 hospitals providing data to the VEMD. Of these, six began to provide data in 2003, one in 2004 and one in 2011. The Data Collections Unit (DCU) of the Health Strategy Productivity and Analytics Division of the Victoria Department of Health manages VEMD operations. Data are collected at each reporting hospital and are transferred in a defined format to the DCU. An annually updated manual provides clinical, nursing and clerical staff with the necessary level of detail to accurately record patient demographics, diagnoses, procedures, injury surveillance and other data for reporting to the VEMD. Explanatory notes are included to promote consistent interpretation of the data items. All persons presenting at EDs are first ‘triaged’ or assessed for objective clinical urgency by a staff member (specifically trained and experienced) according to the five category ATS.5 In the present study we have grouped categories 4–5 (lowest urgency) to contrast with categories 1–3 (highest urgency). Presentation rates per 1000 persons (for each year of presentation and age group) were calculated as a ratio by taking the numerator as the number of presentations to ED (multiplied by
1000) obtained from VEMD, and the denominator as the estimated resident population (ERP) of Victorian residents in each age group obtained from the Australian Bureau of Statistics (ABS).6 Data were analysed using IBM SPSS Statistics Version 20 and Microsoft Office Excel 2003.
Results Absolute numbers of presentations The absolute number of presentations to EDs in Victoria has grown by over 52% in the past 11 years, from 947 238 in 2002/2003 to 1 448 171 in 2012/2013. Triage 1–3 presentations increased by 89% and triage 4–5 by 33%. The age distribution of ED presentations demonstrates a bimodal peak that is consistent over the years studied. Throughout this entire time period, the 5 year age band with the greatest number of ED presentations has consistently been, by far, children 0–4 years of age. This age group has seen an increase of 29% in ED presentations over this time period resulting in 161 988 presentations in 2012/2013. Triage 1–3 presentations in the 0–4 age group grew by 55% and triage 4–5 by 16%. The age band with the second highest volume of ED presentations, also consistently over time, has been those 20–24 years of age. This age band has had an increase of 49% over the same time period and had 112 127 ED presentations in 2012/
2013. Triage 1–3 presentations in the 20–24 age group grew by 95% and triage 4–5 by 32%. In contrast, the age band >65 years with the greatest number of presentations over this period is those 75–79 years. This age band experienced a growth of 45% and had 57 065 presentations in 2012/2013, with a 63% increase for triage 1–3 and a 27% increase for triage 4–5. When examined by triage category, the same age distribution patterns for the absolute numbers of ED presentations are maintained (Figs 1,2). For all age groups, there has been very little change in the number of triage category 4–5 presentations since 2007/ 2008. However, for triage categories 1–3, there have been consistent increases in the absolute numbers of presentations across all age groups.
Population based rates of ED presentations When ED presentations are examined in the context of rates per 1000 persons in specific age bands, a different pattern emerges (Figs 3,4). For triage category 4–5 presentations, rates are highest for the youngest and oldest age bands. Additionally, although similar patterns of these rates occur across all years of our study, population-based rates of such visits have not increased over time. In contrast, for triage category 1–3 presentations, the rates of presentation increase in a consistent pattern
Figure 1. Absolute numbers of ED presentations; triage categories 4 and 5. ( ), 2007/2008; ( ), 2010/2011; ( ), 2011/2012; ( 2003; ( 2013.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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Figure 2. Absolute numbers of ED presentations; triage categories 1–3. ( ), 2002/ ), 2007/2008; ( ), 2010/2011; ( ), 2011/2012; ( ), 2012/2013. 2003; (
that the majority of presentations for those in younger age groups are classified as triage category 4 or 5. After the 10–14 year age band, there is a consistent trend of decreasing proportion of category 4 or 5 presentations. Although this overall trend is consistent over time, triage 4–5 as a proportion of all ED presentations has also fallen for all age groups 64 years, highest in the earlier period up to 2007–2008 and then levelling off. This is consistent with another of our findings that, with increasing age, the proportion of presentations classified as higher urgency increase in a linear fashion beginning at age 25 and continuing thereafter. This trend was consistent over the study period with increasing proportions of visits in higher urgency conditions seen across all age groups. This finding likely reflects that the elderly indeed present with increasingly complex and urgent conditions or that there are aspects to their ED
utilisation patterns that might result in triage categorisation sometimes reflecting a lower urgency than would be appropriate to their clinical condition.2 One potential example would be those seniors for whom transportation to the ED is difficult to obtain and thus rely on ambulances.7–9 Such occurrences might occur more frequently in long-term care facilities where there is a paucity of GP care and even minor conditions prompt transport to the ED for evaluation and treatment.8–11 Without other mechanisms of transport available, ambulances may be utilised and result in a greater urgency in triage classifica-
tion. Further research into such circumstances should be conducted to better understand the root causes of elderly presentations to the ED prior to new policies and strategies being implemented, lest the resources expended not effectively target underlying causes of the problem.1 In the same vein, there has been much speculation regarding the reasons for the overall increased number of ED presentations over time. Some have postulated that problems with GP availability have played a role.2,12 However, objective data on actual same-day GP appointment availability for acute care are lacking in Australia. Perceptions of problems GP in availability are based on anecdote, professional opinion and calculations of GP to population ratios and have not been tested to determine their frequency or distribution across either urban or rural areas. Others have suggested that the gap amount charged over the Medicare rebate in some GP surgeries might be a financial barrier to care.13,14 Again, actual data on gap charges, their geographic distribution and prevalence are lacking. To date, information available to policymakers on the determinants of patient behaviour with regard to ED utilisation mostly has been anecdotal, conducted at single sites of patient care or based on expert opinion, not objective data.12,15 Such information will be helpful in creating policy options that address specifically the underlying causes of increases in ED presentations and can lead to evidence-based, rather than anecdote-based, policy decision. With specific regard to the volume of child presentations to the ED, some have opined that groups of parents might not have sufficient confidence in their GP to care for children, and thus are more likely to bring their child to the ED.12,15–17 Yet, there are limited data on such parental preferences and the reasons why they bring their children to the ED, especially for low urgency conditions. Such information would be helpful to policymakers and those responsible for the organisation and delivery of primary care services to develop strategies with the highest likelihood of success to address the volume of ED presentations for this population.
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Another possibility that might impact the volume of children presenting to EDs is the potential of GPs to refer children to the ED rather than care for them in their surgeries. Previous research has demonstrated that as the demography of Australia has changed, children comprise a progressively smaller proportion of both the general population and of GP visits.18 It is possible this might impact both the comfort of GPs in providing acute care to children, and their currency in paediatric care. Similarly, although there is increasing attention paid to improving the primary care management of chronic illnesses, almost all of the emphasis is placed on adults with conditions such as hypertension or diabetes. However, due to improvements in neonatal care and increased survival of children with other conditions, there are more children alive today with chronic illness than ever in Australia. Nevertheless, the number of extended consultations in primary care (those visits usually associated with the care of chronic or more complex conditions) for children has decreased in absolute numbers over the past two decades.19 It is unclear if these children comprise a significant proportion of ED visits. Future research is required address this issue. Previous studies have sought to determine whether some presentations to the ED categorised as low urgency might be able to addressed in GP offices.2,3,13,20–22 Others have sought to determine the expectations of the public with regard to ED utilisation and the appropriateness of their presentations to the ED.23–28 Limitations of the studies conducted within the last decade include the potential for selfjustification among those presenting to EDs and that all but one excluded children. Some studies were conducted at single EDs and therefore might not be generalisable. Our findings are consistent with those of Lowthian et al.1 but add several more years of recent data. Although we include population specific rates of ED presentations, we focus our results more on the absolute number of ED presentations by age group. Although we also found increased growth in ED presentations among the ageing community, the current volume of ED care
provided to patients at the other end of the age spectrum, across all triage categories, demands greater attention. The reasons for the magnitude of the presentations for children must be assessed to determine where models of care in the healthcare system need to be modified.
hospitals who have provided valuable perspectives to our work.
Author contributions All authors participated in the design of the research, the drafting and/or revision of the manuscript and approved the final product.
Limitations There were six hospitals added to the VEMD in 2003. These additions had an impact on the total number of presentations included in the VEMD subsequent to that year. However, this important caveat does not account for the entire increase in presentations observed. The VEMD is regularly assessed by an external advisory group for data integrity and completeness. The VEMD only contains data collected from EDs in Victoria. As such, our findings might or might not be applicable to other states.
Conclusions Whenever there is significant public attention focused on a topic regarding the health of a population, there is often a sense of urgency felt by policymakers and medical professionals to act expeditiously. Often such action is taken to address the ‘shrill voices’ in the public arena without the data necessary to develop true evidence-based policy options. Using data to drive policy options might take longer, but will result in a greater likelihood of successful action and a greater likelihood of responsible use of public funds. To meet the needs of Victorians, efforts should be made to ensure there is an adequate capacity and workforce within both the primary care as well as emergency services systems to provide care to patients, regardless of their age. The information provided from the present study should help in identifying from which age groups the volume of ED presentations emanate and thus prioritise specific areas for action.
Acknowledgements We thank the Emergency Physicians from both academic and community
Competing interests None declared.
References 1. Lowthian JA, Curtis AJ, Jolley DJ et al. Demand at the emergency department front door: 10-year trends in presentations. Med. J. Aust. 2012; 196: 128–32. 2. Lowthian JA, Smith C, Stoelwinder JU et al. Why older patients of lower clinical urgency choose to attend the emergency department. Intern. Med. J. 2013; 43: 59–65. 3. Nagree Y, Camarda VJ, Fatovich DM et al. Quantifying the proportion of general practice and low-acuity patients in the emergency department. Med. J. Aust. 2013; 198: 612– 5. 4. Victorian Department of Health. Health data standards and systems. Victorian Emergency Minimum Dataset (VEMD). 2014. [Accessed Jul 2014.] Available from URL: http:// www.health.vic.gov.au/hdss/vemd/ index.htm 5. Australian College For Emergency Medicine. Guidelines on the implementation of the Australasian Triage Scale in Emergency Department. Document No. G24, Approved 00 Nov, Last revised 13 Nov, Version No. 03. 2013. 6. Australian Bureau of Statistics. Population by age and sex, regions of Australia 2012. ABS Cat. No. 3235.0. 2013. 7. Codde J, Frankel J, Arendts G et al. Quantification of the proportion of transfers from residential aged care facilities to the emergency department that could be avoided through improved primary care services. Australas. J. Ageing 2010; 29: 167– 71.
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8. Finn JC, Flicker L, Mackenzie E et al. Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia. Med. J. Aust. 2006; 184: 432–5. 9. Ting JY, Chang AM. Path analysis modeling indicates free transport increases ambulance use for minor indications. Prehosp. Emerg. Care 2006; 10: 476–81. 10. Arendts G, Reibel T, Codde J et al. Can transfers from residential aged care facilities to the emergency department be avoided through improved primary care services? Data from qualitative interviews. Australas. J. Ageing 2010; 29: 61–5. 11. Codde J, Arendts G, Frankel J et al. Transfers from residential aged care facilities to the emergency department are reduced through improved primary care services: an intervention study. Australas. J. Ageing 2010; 29: 150–4. 12. Williams A, O’Rourke P, Keough S. Making choices: why parents present to the emergency department for nonurgent care. Arch. Dis. Child. 2009; 94: 817–20. 13. Siminski P, Bezzina AJ, Lago LP et al. Primary care presentations at emergency departments: rates and reasons by age and sex. Aust. Health Rev. 2008; 32: 700–9. 14. Masso M, Bezzina AJ, Siminski P et al. Why patients attend emergency departments for conditions potentially appropriate for primary care:
15.
16.
17.
18.
19.
20.
21.
reasons given by patients and clinicians differ. Emerg. Med. Australas. 2007; 19: 333–40. Ryan M, Spicer M, Hyett C et al. Non-urgent presentations to a paediatric emergency department: parental behaviours, expectations and outcomes. Emerg. Med. Australas. 2005; 17: 457–62. Cooper C, Simpson JM, Hanson R. The district hospital emergency department: why do parents present? Emerg. Med. 2003; 9: 68–70. Woolfenden S, Ritchie J, Talbot-Stern J et al. Parental use of a paediatric emergency department as an ambulatory care service. Aust. N. Z. J. Public Health 2000; 24: 204–6. Freed GL, Sewell J, Spike N et al. Changes in the demography of Australia and therefore general practice patient populations. Aust. Fam. Physician 2012; 41: 715–9. Freed GL, Spike NA, Sewell JR et al. Changes in longer consultations for children in general practice. J. Paediatr. Child Health 2013; 49: 325–9. Ng JY, Fatovich DM, Turner VF et al. Appropriateness of healthdirect referrals to the emergency department compared with self-referrals and GP referrals. Med. J. Aust. 2012; 197: 498–502. Bezzina AJ, Smith PB, Cromwell D et al. Primary care patients in the emergency department: who are they? A review of the definition of the ‘primary care patient’ in the emer-
22.
23.
24.
25.
26.
27.
28.
gency department. Emerg. Med. Australas. 2005; 17: 472–9. Sprivulis P. Estimation of the general practice workload of a metropolitan teaching hospital emergency department. Emerg. Med. 2003; 15: 32–7. Toloo GS, FitzGerald GJ, Aitken PJ et al. Ambulance use is associated with higher self-rated illness seriousness: user attitudes and perceptions. Acad. Emerg. Med. 2013; 20: 576– 83. Morgans A, Burgess S. Judging a patient’s decision to seek emergency healthcare: clues for managing increasing patient demand. Aust. Health Rev. 2012; 36: 110–4. Morgans A, Burgess SJ. What is a health emergency? The difference in definition and understanding between patients and health professionals. Aust. Health Rev. 2011; 35: 248–9. Callen JL, Blundell L, Prgomet M. Emergency department use in a rural Australian setting: are the factors prompting attendance appropriate? Aust. Health Rev. 2008; 34: 710– 20. Abernethie L, Nagree Y. Increased emergency department attendance: a qualitative investigation of health seeking behaviours. Just Policy 2004; 33: 6–16. Liaw ST, Hill T, Bryce H et al. Emergency and primary care at Melbourne hospital: reasons for attendance and satisfaction. Aust. Health Rev. 2001; 24: 120–34.
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