The subject of increasing emergency department (ED) visits is well recognised by western healthcare systems. In particular, whether it was necessary or appropriate for many of these patients to visit ED remains a vexed question. As such, understanding sub populations that visit the emergency department may offer insight and data into how best to deliver the right services in the right settings, while informing operational planning for ambulance services.
The sub-populations that form the focus of this retrospective population-based cohort study are those patients brought to the ED by ambulance, are triaged, but subsequently leave before consulting an ED health provider. This phenomenon has been termed within this paper as a paradoxical visit (PV).
The study setting was the Winnipeg Health Region (WHR), Manitoba, Canada (population 720,000). Between the 1st of April 2012 and the 31st March 2013, the researchers examined anonymised ED records of those visitors ≥17 years old, to capture single and multiple PVs. These were then assessed to establish the prevalence of PVs, the demographics and health status of this sub population of ED visitors.
Overall, the study cohort comprised 122 639 patients. Across all participating ED sites, 2.3% of patients (n=2815) made 3387 PVs (1.4% of all ED visits in the study period), which equates to approximately 9 visits per day (n=2515). 89.3% of these were single visits, 0.8% (n=22) had fewer than 6 visits.
The paper takes a novel approach insofar as it compares patients making PVs with frequent ED visitors, the latter being those with a chronic health burden and demonstrates that PV patients are indeed different in several ways; they tended to be younger, lived in low income areas and typically have a history of substance abuse. They do not however appear to have a disease burden consistent with the frequency of their ED visits, a point further made by data indicating they were less likely to die following their last ED visit.
The paper was initially a challenging read, with a surfeit of data spread across three tables and writing style that, on occasion, could have been more succinct. This notwithstanding the paper makes an interesting contribution to the debate surrounding ‘appropriateness’ of ED visits and alternative models of unscheduled care.
The conclusion of the paper suggests that PV patients as a sub-population of ED visitors are not burdened by disease but rather sociodemographic problems and substance abuse; therefore their health needs are unlikely to be best served in an ED setting, which may explain why they leave before consultation. Moreover the suggestion that these patients may be better served by increasing social work and substance abuse counselling in the ED potentially challenges the core beliefs of what an ED should actually be. Indeed the paper closes by proposing that contrary to a widely held belief that the ED serves as a surrogate for other healthcare services, this is not supported by the study.
Overall, this is an interesting paper that challenges a number of cultural tropes regarding ED use and how best to address it. The strengths of the study lie in the richness of its data and the way this informs the discussion and conclusion. Undoubtedly, many pre-hospital providers will recognise and probably have dealt with PV patients during their careers, and may gain greater insight into this group having read the paper.