The aim of this study was to develop a reliable and replicable means of differentiating low-acuity attendances in routine clinical information documented in German EDs. The results indicate that while a majority of ED attendances exhibited the genuine life threatening conditions for which these services are designed, a significant proportion of attendances did not require ED assessment (33.2%). Though these low-acuity attendees may have perceived the need for immediate attention from a medical professional, the systematic criteria utilized in this study indicate that they did not require immediate medical care.
Interpretation and practical consideration
Though the final figure of low-acuity attendances produced by this study may seem high, within the context of the German Health Care System it is unsurprising. While previous studies have been unable to accurately identify and quantify their impact, the presence and detrimental impact of these Low-acuity presentations in Germany has long been recognised 1–9. Moreover, given the lack of a nationwide system of gatekeeping regulating access to urgent care services this figure is not unexpected.
To date there remain primarily two ways of accessing health care in Germany. For routine and non-urgent care, service users can access a primary care sector which includes all General Practitioners and Specialists treating service users on an outpatient basis 25. For urgent care and care outside primary care opening hours, patients can go to a hospital ED or visit ‘Out of Hours’ primary care (OOH) which remains in it’s infancy in Germany 26. Importantly, the decision to attend any of these services, is in theory at least, unfettered by the service user’s finances, condition and referral.
With that said, lack of gatekeeping and primary care alternatives to the ED alone cannot explain these attendances 27. While it is beyond the remit of this paper to explain these attendances, attitudinal research has shown that the decision to seek medical help is shaped by a complex web of contributing factors including: service user characteristics; lack of confidence in or access to primary care; perceived need for immediate care; proximity and convenience; and the perceived efficacy of urgent care services 11,28−31. This has significant implications for what service users define as a life threatening emergency and maybe at odds with professionally defined health needs, namely, ´the needs for health services as recognised by health professionals from the point of view of the benefit obtainable from advice, preventative measures, management or specific therapy´ 32.
Reasoning aside, as major contributor to ED overcrowding, the results provide clear evidence that this these low-acuity attendances represent a huge strain on the German Health Care system. Irrespective of the number of patients in the ED at any given time this type of attendance is detrimental to both the health service provider and user alike. In point of fact, in addition to their impact on individual service users quality of care 12–15, it has been claimed that as each patient covered by state health insurance presenting at the ED results in a loss of 80 euros 21 every low-acuity presentation represents a potentially unnecessary financial burden.
Comparison of methods to identify low-acuity attendances in the ED
Despite widespread recognition of the detrimental impact of low-acuity ED attendances and long established body of peer review literature 33–35 there remains no universally accepted terminology or definition of this type of ED presentations. Consequently, a number of different methods and criteria have been developed to identify and quantify the impact of this type of attendance leading to significant variation in estimates on both a national and international level 36.
Differences in definition and terminology aside, the exact criteria utilized by individual studies is largely dependent upon the available routine clinical information documented in the ED. As such, a wide range of criteria has been utilized to identify and quantify this type of attendances including; arrival type; comorbidities; diagnoses; hospital admission; presenting condition; referral type; resources used; triage evaluation and vital signs 37: making comparison of estimates difficult 38. The exact combination of criteria, and the diversity of approaches which arise from such, should also therefore be understood within the context of differing health care systems.
The data items of the recommended model are in line with current recommendations on ED documentation given by the working group on Emergency Documentation in Germany 39. These data items are as well included in the current data set of the AKTIN-registry (the German ED routine data registry) 40. Furthermore they are part of the data items defined as “Notfallkerndatensatz” (NoKeDa 41) in collaboration of the DIVI-working group and the Robert Koch Institute in Germany 42.
The criteria utilized and promoted by this study are common throughout the literature. In particular, triage evaluation is a key data point in many studies 43–50. Though these systems alone are an insufficient measure of low-acuity attendances due to the dynamic state of service users’ conditions 51, as a consistent and valuable feature of administrative data 1 when used in tandem with the other data points commonly available in routine ED data such as mode of arrival, admission status or survival 13,52−56, triage scores provide an important foundation element of many approaches.
Though further information such as hospital resources including imaging, diagnostic tests, procedures, or medications ordered are also used to identify low-acuity attendances 12,57,58 this information is not widely available in routine ED data in Germany and furthermore the availability of these resources in the primary care setting varies across locations and settings and could as well be improved in the future and thus would not necessarily require treatment in an ED.
Strength and Weaknesses of the study
As the first study to provide a reliable and replicable method for accurately identifying and quantify the proportion of low-acuity attendances across urgent care services in Germany, this study provides a vital tool for the advancement of targeted and evidence-based policy solutions in the German Health-Care system. Indeed, to date, no study has been able to accurately quantify and characterise attendees who do not require ED assessment. In providing a method for doing so, this study enables the furthering of patients-centered health care for high and low-acuity patients alike.
Furthermore, while the impact of low-acuity attendees is widely accepted, the direct impact of low-acuity attendances remains under-researched. By establishing an accurate method of identification and quantification, this study paves the way for future research into the direct impact of low-acuity attendees on the provision of urgent care services. For example, while much has been made of the relationship between low-acuity attendees and ED overcrowding, evidence of their relationship to one another is often over-stated 59. By accurately identifying which patients require and do not require ED assessment, the method detailed in this study provides a means of measuring their direct impact.
Potential gains aside, it should be noted that as ED documentation in Germany remains unstandardized and electronic documentation is not yet implemented comprehensively 60, data items that could not be considered in this study due to data availability and quality could have further improved this method of classification. As it stands, the current method makes use of the most widely available clinical data points enabling the highest number of potential applications across the German Health System and internationally.