Is there excessive use of emergency care by walk-in patients?

The inappropriate use of Emergency Department (ED) service by patients with non-urgent health problems is a worldwide problem, including in Portugal. Nowadays, with the COVID-19 pandemic, the problem is growing and the subject is again on the agenda.

Every patient admitted to the ED is submitted to a risk stratification (RS) assessment. Among the various recognized RS systems, the Manchester Triage System (MTS) has international dissemination. MTS establishes five categories/clinical priorities, instituting a colour for each of them. In declining order of health risk these are red (emergent), orange (very urgent), yellow (urgent), green (standard) and blue (not urgent).

Most studies focus on the supply side, identifying greens and blues according to MTS as inappropriate. This paper considers in addition that demand for health care services results from an individual choice process. Thus, not only referred patients (either from primary care or SNS 24 helpline) should not be viewed as inappropriate, but also that the proportion of greens and blues should be significantly higher for patients who freely decide to go to the ED.

The paper reports data that show that things aren’t as expected (see figure). The proportion of greens and blues in walk-in admissions (patients showed up by their own decision at the ED) is 36,5% (32,4% plus 4,1% in the figure). In contrast, the proportion of greens and blues in people who went to the hospital emergency after having gone to primary care is 30,7% (26,8% plus 3,9% in the figure), and the proportion of greens and blues that were admitted to hospital ED after SNS24 helpline indication were 23,3% (22,3% plus 1% in the figure). That is, even in cases where there were prior contact with the National Health Service, the proportions of non-urgent cases (blues and greens) are high.

The paper concludes that access to a health care service before being admitted to ED is effective and SNS 24 helpline triage is more efficient than that of family doctors (primary care). However, without additional information about symptoms to incorporate in the study, it appears that a large majority of greens and blues that are walk-in admissions cannot be considered inappropriate.

Click here to go to the paper by Patrícia Alves da Rocha.