A Retrospective Review of Emergency Department Visits That May Be Appropriate for Management in Non-Emergency Settings

ABSTRACT Background Emergency departments (EDs) continue to struggle with overcrowding, increasing wait times, and a surge in patients with non-urgent conditions. Patients frequently choose the ED for non-emergent medical issues or injuries that could readily be handled in a primary care setting. We analyzed encounters in the ED at the Brooke Army Medical Center—the largest hospital in the Department of Defense—to determine the percentage of visits that could potentially be managed in a lower cost, appointment-based setting. Materials and Methods We conducted a retrospective chart review of patients within our electronic medical record system from September 2019 to August 2020, which represented equidistance from the start of the COVID-19 pandemic, resulting in a shift in ED used based on previously published data. Our study also compared the number of ED visits pre-covid vs. post-covid. We defined visits to be primary care eligible if they were discharged home and received no computed tomography imaging, ultrasound, magnetic resonance imaging, intravenous medications, or intramuscular-controlled substances. Results During the 12 month period, we queried data on 75,205 patient charts. We categorized 56.7% (n = 42,647) of visits as primary care eligible within our chart review. Most primary-care-eligible visits were ESI level 4 (59.2%). The largest proportion of primary-care-eligible patients (28.3%) was seen in our fast-track area followed by our pediatric pod (21.9%). The total number of ED visits decreased from 7,477 pre-covid to 5,057 post-covid visits. However, the proportion of patient visits that qualified as primary care eligible was generally consistent. Conclusions Over half of all ED visits in our dataset could be primary care eligible. Our findings suggest that our patient population may benefit from other on-demand and appointment-based healthcare delivery to decompress the ED.


Background
Overcrowding in emergency departments (EDs) has increased over the years, leading to delays in care and an increase in negative patient outcomes. 1 Overcrowding is defined as "the situation in which ED function is impeded primarily because of the excessive number of patients waiting to be seen, undergoing assessment and treatment, or waiting for departure comparing to the physical or staffing capacity of the ED." 2 A major culprit of this increase is a surge of non-urgent patients presenting to the ED. Previous studies have estimated that 13-27% of ED civilian visits are primary-care-eligible visits that could be managed in an appointment-based setting. 3,4 Previous studies have reported possible motives as to why non-emergent patients choose the ED over primary care providers. Patients often choose the ED over other facilities due to various reasons including easy accessibility and the convenience of being an easy solution to comprehensive healthcare problems with the ability to perform rapid workups and evaluations. 5,6 During the Coronavirus (COVID-19) pandemic, most patients reported having difficulties scheduling an appointment or self-reported as having an emergent condition (Tapia et al. pending publication, U.S. Army Medical Journal).
Several negative consequences have been associated with ED overcrowding. A major consequence is longer wait times leading to delays in care, which not only affect the non-urgent patients but also the critically ill patients. 7 According to the Centers for Disease Control and Prevention, 10% of nonurgent patients wait over an hour to see a physician. 8 Longer delays can cause serious complications such as decreased patient safety, reduced quality of care, and an increase in mortality rate. 2 Overcrowding also causes an increase in length of stay and an increase in patients leaving without being seen, both of which cause losses in revenue and can endanger more urgent patients that became frustrated and left. 9 ED overcrowding has costly effects on the Military Health System (MHS), with ED visits not only being more expensive than primary care appointments but those beneficiaries also have prolonged periods of lost work time. Misuse of ED resources for routine care delivery contributes to unnecessary inefficiencies and monetary costs associated with ED operations required to plan for surges in visits that are often unpredictable. These issues have a negative effect on military readiness by diluting the proportion of ED visits requiring emergency care and other interventions relevant to the deployment mission. Based on internal data from BAMC, 30-40% of daily visits were triaged as Emergency Severity Index (ESI) 4s and 5s, which represent non-urgent visits. 10 Meanwhile, the number of unbooked primary care appointments is typically above 10% on average. These data sets display inefficient ED resource utilization. Patients frequently experience prolonged ED wait times for minor issues, which are often easily handled by primary care providers.

Goal of This Study
We seek to determine the proportion of patients that visited the ED at BAMC that were primary care eligible and would presumably be readily manageable in an appointment-based setting.

Ethics
We submitted a research determination to the Regional Health Command-Central regulatory office. They reviewed our project and determined whether it met the primary definition of process improvement and did not require institutional review board oversight.

Subjects and Settings
Our study setting took place at the Brooke Army Medical Center (BAMC) at Joint Base San Antonio, Texas over a 12 month period, from September 1, 2019 to August 31, 2020. BAMC is the only level 1 trauma center in the DoD. The ED had nearly 84,000 visits during the last calendar year. The facility also serves as a public regional trauma center. The ED in BAMC is comprised of sections called "pods" with each area having a specific patient focus; fast track, pediatrics, adult high-and moderate-acuity, and traumas/resuscitations. The department features an emergency medicine residency program with 16 residents per year over the 3 year program split between the Army and Air Force. The residency program also supports ultrasounds (USs), emergency medical services, and hyperbaric fellowship programs. BAMC is the largest hospital in the DoD with the largest Graduate Medical Education system.

Data Acquisition
We conducted a retrospective chart review of patient encounters triaged as non-emergent to determine what proportion could likely undergo management in a non-ED setting. Inclusion criteria consisted of any ED visits during our study period. We queried the electronic medical record (EMR) system, T-System TM (Plano, TX), for encounters during the outlined study period. T-System is the EMR system in use in our ED that relies primarily on specific data entry fields (dates, times) and checkbox-type charting (complaints, physical exam, predefined medical decision-making pathways, etc). Data were extracted automatically from EMR fields that are based on specific data entry type (date, time), checkbox (e.g., review of systems, physical exam), and limited free text entry (e.g., chief complaint) into the spreadsheet database by way of extraction parameters predefined for performance improvement analyses and department metric tracking.

Measures
The primary outcome for the study was the determination of whether each patient could be managed in a non-ED setting, which we referred to as primary care eligible. We based our definitions upon those features that in our estimation as healthcare providers characterize clinical scenarios for which management could feasibly occur with a routine clinic visit. We reviewed all available medical records during the search timeframe for categorization. Patients were identified as primary care eligible if they were discharged to home, were not given any intravenous (IV) medications, and had no advanced diagnostic imaging, including computed tomography (CT), magnetic resonance imaging (MRI), or US; otherwise, patients were considered not primary care eligible. Patient characteristics included acuity level, arrival mode, final treatment area, procedures, complaints, and discharge status. Acuity level was measured as categories from 1 (most urgent) to 5 (least urgent) or missing. Arrival modes were categorized as ambulance, automobile, helicopter, not available, police, walk-in, and unknown/other. The final treatment areas were categorized as pediatric, adult, observation, fast track, and waiting room. Procedures were grouped into IV medications and advanced diagnostic imaging. Patient complaints/diagnoses were grouped into category-based text entry and then rank-ordered into the ten most frequently occurring complaints. Patient discharge status was categorized as admit, discharge, left (against medical advice/unseen/prior to registration), transfer to other facilities, expired, and not available or missing. Additionally, to compare the number of visits and patient characteristics before and after the onset of the COVID-19 pandemic,we grouped patients with arrival dates from September 2019 to February 2020 as pre-covid and patients with arrival dates from March 2020 to August 2020 as post-covid. We included all available encounters within these time periods.

Data Analysis
We performed all statistical analyses using IBM SPSS Statistics (version 27, Chicago, IL). We presented continuous variables as means with standard deviation (SD). We presented nominal variables as percentages and 95% confidence intervals (CIs). We used the nonparametric Mann-Whitney U test for non-normally distributed continuous variables and the Chi-square test for nominal variables.

RESULTS
During the 12 month period, we queried data from the EMR on 75,205 patient charts. Within our dataset, shown in Table I, there were 56.7% (n = 42,647) that were primarycare-eligible. Out of those encounters, 59.2% were ESI 4 and 6.4% were ESI 5. When reviewing the top 10 complaints or diagnosis for primary-care-eligible patients, Table II indicates the largest proportion is respiratory infections at 28.7%. Followed by 10% for injuries, 7.6% for heart/chest pain, and all others under 5%. There was a small number of primary-careeligible patients that arrived at the ED by ambulance, as shown in Table I.
Dividing our data into areas, the largest proportion of nonurgent patients was in the adult areas at 49.1%, followed by fast track at 28.3% and the pediatric pod at 21.9%, leaving less than 1% for both observation and the waiting room. We had a mean of 3,554 primary-care-eligible patients a month at the lowest point of our study.
Our study also compared the number of ED visits pre-covid vs. post-covid, as shown in Table III. The total number of ED visits decreased from 7,477 pre-covid to 5,057 post-covid visits per month. However, the proportion of patient visits that qualified as primary care eligible stayed approximately the same, pre-covid 58.9% (n = 4,406) and 53.4% (n = 2,702). This trend continued in the number of ED visits in each pod, with a majority of patients in the adult pods (47.4% pre-covid and 51.8% post-covid) followed by the pediatric area at 22.9% pre-covid and 20.4% post-covid and then fast-track patients at 29% pre-covid and 27% post-covid.
We found the most frequent chief complaint associated with being primary care eligible was a respiratory infection (28.7%). However, while injury was the second most frequent primary-care-eligible complaint (10.0%), most of them were considered to be needing ED-level care (16.5%). There was decrease in overall ED visits and the comparison of primarycare-eligible patients compared to ED eligible patients in the pre-and post-COVID time periods (Fig. 1, Supplementary  Fig. S1).

DISCUSSION
In this study, we analyzed 72,205 ED visits of which over half of the encounters we determined were primary care eligible. According to our findings, nearly 3 of 5 patients during the study period were deemed "primary care eligible" and could have been managed without resorting to an ED visit. With the average time of stay at the ED being over 3 h, these unnecessary ED visits are costly for those within the workforce. Furthermore, ED visits for symptoms that are treatable in primary care settings are less cost-effective and lead to increased societal financial burden. 11,12 This highlights a potential population of visits where determining the needs of the military beneficiaries may result in better access to care, reduced missed time from work, and reduced ED utilization. Most importantly, appropriate ED utilization would result in system-wide cost savings for the MHS and the DHA.
We also compared the difference in patient volume preand post-COVID-19 pandemic. While the total number of average monthly visits decreased from 7,477 pre-covid visits to approximately 5,057 visits post-covid, the proportions of patients triaged ESI 4 or 5 remained approximately the same at over half of primary-care-eligible patients, suggesting that even with a pandemic going on, the same proportion of total visits to the ED were non-urgent patients. A previous study done at BAMC showed a higher proportion of ESI levels 1-3 and a drop in ESI level 4 patients (Long et al. pending publication, Military Medicine). Our study analyzed the combinations of both ESI level 4 in proportion to the total level of ED visits. The proportion remained in the same range while there was a decline in the total number of visits during COVID. Previous studies show the significant decrease in non-serious visits during the pandemic was a worldwide occurrence and was most likely due to fear of being infected by COVID-19 and the fears of contributing to the risk of overwhelming the ED. 6,13 Increased use of the ED affects the quality of services in the ED. The quality of care is highly impacted on the resources available, including the staff on shift and the medical equipment available with longer wait times due to a finite number of rooms and staff. Consequences to overcrowding include overworked medical staff, causing fatigue and lowering their ability to adhere to treatment guidelines causing poorer patient outcomes. Fast track or minor care areas represent a strategy to alleviate this issue, a system put into place to help those patients with minor injuries or illness. 13 Our dataset showed 28.3% of ED encounters were sent to fast track, suggesting that most of the primary-care-eligible patients could be seen quickly without taking resources or time from urgent patients. Another option would be urgent-care clinic within close proximity to the ED.     Previous studies completed by military audit agencies reported that military hospitals provide care for mostly nonurgent, low acuity care often for the convenience of military health beneficiaries. 14,15 A GAO report analysis of emergency data from six military EDs showed that between 54 and 95% of the services provided were for non-emergency or non-urgent conditions. 16 The presence of an ED is often justified based on readiness or training requirements or the fact that civilian emergency care is not readily available near the military treatment facility. 16 Solutions to decrease overcrowding have been suggested in previous studies. Many hospitals have started to implement a fast-track system, which is currently being used at BAMC. However, during peak times when fast-track or rapid treatment areas are full, another strategy could be implementation of an appointment-based system that is readily accessible across "teams" of care and locations within the MHS. 17 These strategies might alleviate overcrowding, but other studies have focused on improving other parts of healthcare to tackle the source of the problem. Easier access to their primary care clinic with ready access to available appointments may reduce non-urgent visits to the ED. Examples such as late weeknight appointments or even weekend appointment availability can lower the non-urgent visits to the ED (Tapia et al. pending publication). Other options include offhour telehealth visits, a system that eliminates the need for prolonged phone calls and difficult-to-navigate bureaucratic systems, allowing patients to be seen by other primary care clinics with open appointments that may not be their primary location, which ensures that empty appointments are filled across the San Antonio Military Health System.
The Coronavirus (COVID-19) pandemic impacted our study, starting from March 2020 to the end of our data extraction in September 2020. The pandemic caused a drastic drop in patient visits starting in March and continued to drop to its lowest in April 2020 at a mere 3,758 patient visits. People were encouraged to stay home by government and health officials, and local hospitals and clinics offered telemedicine appointments to accommodate patients with mostly nonurgent conditions or needs. The ED at BAMC never closed but had to adapt to the health crisis.
Our study had several limitations. Starting with the most obvious, the pandemic causing a decrease in ED visits during our time span. We only analyzed data prior to patient discharge, excluding any possible related return visits and how that may have altered primary care eligibilities. The use of ESI 4 and 5 to define non-urgent patients could have affected our data because this scoring system estimates nursing resources needed and not necessarily the acuity of their disease or illness. Thus, it is possible we missed patients that may have warranted a higher ESI level. Our low percentages for observation and waiting room could be due to patients being discharged from the waiting room or patients could have left without being seen. Additionally, we must highlight that we are performing this based on data in a retrospective method, which is limited in that we can only assess variables captured within the EMR in aggregate. Some complaints may have exceeded the comfort level of the medical personnel in the primary care setting but would still appear to be low risk by our inclusion criteria. The need for specific laboratory studies, despite being available with point-of-care testing (e.g., troponin testing), may exceed the comfort level of the clinical medical personnel. We were not able to directly compare billing differences between an ED visit and a primary care visit due to the fact that our EMR system does not associate visits with billing codes. Additionally, our EMR system is unable to capture where the ambulance visits are from, restricting us from extracting the data for a larger scale. Moreover, we did not evaluate for more interim models of urgent care visits such as those attached to free-standing EDs that have capabilities above that of a routine office visit but not to the level of a full-scale ED within a level 1 trauma center. Therefore, we cannot speak to whether the encounters in our dataset deemed not primary care eligible necessarily required an ED visit. Lastly, we must also note that we were not able to readily evaluate return visits and determine if a "primary care eligible" visit would have resulted in an ED visit anyways. Future work would benefit from implementation and analysis of usage of interim care delivery solutions such as walk-in urgent care centers.

CONCLUSION
Over half of all ED visits in our dataset could be primary care eligible. Our findings suggest that our patient population may benefit from other on-demand and appointment-based healthcare delivery to decompress the ED.