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Emergency Department Demand Increased 37% over a Decade, Study Finds

Wednesday, February 8, 2012 8:08 am EST
"This growth in demand exceeds general population growth, and the variability between states both in utilisation rates and overall trends defies immediate explanation"

Demand for public emergency department (ED) care increased by 37% over the decade ending at the beginning of 2010.

This is the finding of a study published in the latest issue of Emergency Medicine Australasia, the journal of the Australasian College for Emergency Medicine.

Professor Gerry FitzGerald and colleagues from the School of Public Health at the Queensland University of Technology found significant differences in both utilisation rates and in trends in growth among states and territories – differences that do not easily relate to general population trends alone.

“This growth in demand exceeds general population growth, and the variability between states both in utilisation rates and overall trends defies immediate explanation,” Professor FitzGerald said.

“The growth in demand for ED services is a partial contributor to the crowding being experienced in EDs across Australia.”

In the paper, the researchers said the crowding of EDs has been extensively described and linked principally to access block and bed shortages.

The causes of ED crowding are complex and caused by a combination of input (demand), throughput (e.g. patient processing) and output (e.g. access block) factors, they said.

Demand has been consistently increasing over the last decade in all locations except the ACT.

The ED utilisation rate in Australia, which is currently 331 per 1000 persons, has been growing at an average of 1.8% per annum over the past decade.

The so-called “inappropriate users” or “GP” patients have been commonly blamed for increasing demand for ED services.

Many studies use a combination of the triage categories 4–5 and “non-admitted” as an indicator of low-acuity patients who can be cared for outside the ED. However, the Australian Institute of Health and Welfare reports showed that the proportion of patients in the Australasian Triage Scale (ATS) 1–5 has remained fairly stable.

Similarly, admission rates have also remained unchanged.

The researchers described the ATS as an imprecise estimate of appropriateness, imprecision drawn not only from the variability in its application but also from the nature of urgency and its relationships to other concepts, such as severity or appropriateness.

“Admission rates can reflect something of the severity of the patient. However, admission rates are also impacted on by hospital policies and by other societal influences.

“Although it is not reasonable to extract from this information judgements about the appropriateness of ED attendances, it is at the very least possible to state that there is no evidence that increased demand or utilisation is due to overuse by lower-acuity patients or ‘inappropriate use’ based on retrospective clinical judgements.”

A small change in the median age of a population can have dramatic effects on public health services, Professor FitzGerald said.

The median age of the Australian population has increased by 4.8 years over the last two decades.

Tasmania experienced the largest increase in median age over the last 20 years, increasing by 7.8 years from 32.1 years in 1990 to 39.9 years in 2010.

Calculations based on ABS reports show that the population aged 65–84 increased at an average annual rate of 2.03% and 85-year-olds and over increased at 4.66% annually over the past decade.

“It is assumed that the elderly are more likely to require health services, including emergency health services, than younger people.

“However, the ageing might not necessarily explain the whole trend of increasing ED usage. For instance, although the ACT had the highest growth of 7.65% in the number of persons aged 85 and over, its ED presentation rates did not change significantly.

“Also, in a separate analysis of ED presentations at Queensland public hospitals, we found that the presentations per 1000 persons decreased for the over 60 age group in the 5 years between 2003–2004 and 2008–2009, but increased among the 0- to 14-year-old group,” the researchers said.

“There might be a multiplying effect of changing community attitudes to elderly people (wanting to do more) and declining general practitioner availability or involvement in after hours care.

“Population projections suggest increases in the proportion of the population over the age of 65, and this increased proportion is likely to have an ongoing impact on ED demand.”

In ongoing research Professor FitzGerald and his colleagues hope to identify the factors underlying increasing utilisation by analysing in detail the characteristics of users and their reasons for using EDs.

These analyses may result in alternative service delivery models that might appropriately and safely manage future demand.

The work is particularly important given the introduction this year of time-based targets into all Australian emergency departments.

doi: 10.1111/j.1742-6723.2011.01492.x

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