Discovering the patient's definition of a medical emergency.
Purpose: To discover what motivates patients to seek emergency department (ED) care through their definition of a medical emergency.
Design and Methods: A qualitative design using a general inductive approach was conducted with 55 patients at three southeastern EDs. Triangulation of data collection was achieved through the completion of observational notes, demographics form, medical scenarios and symptoms form, and semi-structured interviews which were tape recorded. The interviews focused on patients' definition of a medical emergency.
Findings: Overwhelmingly, patients related pain as a medical emergency though many different aspects of pain emerged such as severity, unrelenting, fear of serious illness, and immediate need for care. Additionally, patients responded with the following definitions of a medical emergency: something life threatening, the need for urgent or quick care, the need for medical assistance, and inability to see primary care provider.
Conclusions: Patients perceive a broad and ill-defined perception of a medical emergency, which has developed from patients' past medical and family experiences. Patients have a broad, colloquial understanding of a medical emergency and perceive an emergency based on their personal understanding of the medical condition present.
Patients seek ED care for health care providers' medical expertise and knowledge of treatment options. Patients must understand basic medical conditions and treatment options in order to decipher the correct use of the ED.
Discovering the Patient's Definition of a Medical Emergency
In 2004, the National Hospital Ambulatory Medical Care Survey (NHAMCS) reported an estimated 110.2 million annual emergency department (ED) visits, an 18% increase since 1994 (McCraig & Nawar, 2006). The increase usage of the ED has led to its overuse and misuse, where as many as 75% of patients present with non-urgent symptoms (Young, Wagner, Kellerman, Ellis, & Bouley, 1996; Billings, Parikh, & Mijanovich, 2000). The dramatic increase in ED utilization during the past decade is a complex issue with numerous contributing factors. A significant contributing factor is the convenience of ED care, including continuous hours of operation, geographical location and no appointment necessary for evaluation (Ragin et al., 2005). Additional reasons include access, need, referral, familiarity and trust, all which influence patients to choose emergency medicine (Afilalo et al., 2004).
The increase in ED use has led to ED overcrowding which has many negative effects on the patients, health care providers, and hospitals. Overcrowding is an international concern that is common in North America, United Kingdom, and Australia (Sprivulis et al, 2006; Trzeciak & Rivers, 2003). Negative effects include: increased patient mortality (Sprivulis, Da Silva, Jacobs, Frazer, & Jelinek, 2006; Richardson, 2006), reduced quality of care (Trzeciak & Rivers, 2003), delay of necessary treatments such as pain medications (Derlet & Richards, 2000), antibiotic administration (Shah, Schmit, Croley, & Meltzer, 2003), and patients' unnecessary exposure to nosocomial infections (Shah et al., 2003).
Many programs and proactive measures have been developed in order to decrease patient usage of the ED such as patient education (Powell & Breedlove-Williams, 1995), telephone triage (LaFrance & Leduc, 2002), access to office appointments (Davidson, Giancola, Gast, Ho, & Wadell, 2003; Cunningham, 2006), pre-authorization (Franco, Mitchell, & Buzon, 1997; Young & Lowe, 1997), and increased insurance co-payment (Cunningham, 2006), which have only produced short term results.
This study set out to discover what motivates patients to seek ED care through the patient's definition of a medical emergency. Current research supports the notion that patients choose ED treatment for multiple reasons. Therefore, a single intervention will not prevent all unnecessary use of the ED. Health care providers need to be aware that a patient's definition of a medical emergency may differ from the medical community's definition, suggesting that exploration of the patient's definition could provide supportive insight into their overuse and misuse of the ED (Afilalo et al., 2004). Therefore, future methods may be developed in order to educate patients on the proper use of the ED and to provide health care professionals the foundation to create programs to remedy the misuse and overuse of the ED.
This qualitative study took place at a large academic medical center, a small private hospital, and a moderate sized private hospital within a metropolitan, southeastern city. Institutional review board approval was obtained from all three hospitals and consent was obtained from all participants.
A total of 55 patients from all three hospitals completed the study. No predetermined demographic data, such as race or sex, was expected secondary to the unpredictability of patients who utilize the ED. Participants were limited to ED patients, whose age was greater than 18, and seeking care at the three metropolitan hospitals. Patients with an altered mental status such as dementia, intoxication, drug abuse, or severe medical conditions were excluded from the study.
Triangulation of data collection was conducted through the completion of observational notes, demographics form, medical scenarios and symptoms form, and semi-structured interviews which were tape recorded. Questions on the demographics form included age, race, gender, educational level, occupation, income, and source of ED payment. The second phase of the data collection consisted of a list of medical scenarios that the participants determined if the scenario was a medical emergency or not. Also, patients were given a list of signs and symptoms and asked to choose whether they believed the sign or symptom was an emergency and whether they would utilize the ED for the condition. Finally, patients underwent an in-depth, semi-structured interview. Interview questions focused on the patient's definition of a medical emergency.
General inductive approach of data analysis was utilized which allowed recurrent or significant themes from the data to emerge without strict constraints (Thomas, 2006). The following procedure was used for inductive analysis of the qualitative data: (1) preparation of raw data files, (2) close reading of the text, (3) creation of categories, (4) overlapping coded and un-coded text, and (5) continuing revision and refinement of categories. The preparation of the raw data required formatting the data in a common format (Thomas, 2006). Interviews were voice recorded and transcribed to Microsoft Word documents with similar font and margins. Close reading of the transcripts was completed with multiple readings in order to identify themes and categories, and to consider possible relationships and differences among categories.
The creation of codes or categories emerged, but initially appeared general. Coding organized the data into conceptual categories, which were analyzed to create themes or concepts. Analysis of the main research study question was completed with a coding system, however, some data collected did not require coding for data interpretation. Continuation of revision and refinement of the category/code system was completed. Many categories that shared similar text were combined.
Trustworthiness was ensured by use of coding consistency check, triangulation of data collection, and a detailed audit trail. Inter-rater coder reliability was accomplished through a secondary coder. A reliability score of 96% was obtained. A detailed audit trail of all events that took place throughout the study was maintained.
An array of definitions of a medical emergency emerged from the data, with pain being the number one response. Additionally, patients responded with the following definitions of a medical emergency: something life threatening, the need for urgent or quick care, the need for medical assistance, and inability to see primary care provider (PCP).
Overwhelmingly, patients correlated pain as a medical emergency. Sub-categories of pain emerged from the data to include severity, unrelenting, fear of a serious illness, and immediate need for care.
Severity of Pain
Patients had a wide range of symptoms they associated with pain including abdominal pain, headache and back pain. Patients viewed the intense level of pain as an emergency. For example, one patient provided the following description, "Stabbing, shooting, or me getting down like I did a while ago. Yes, pain where you almost pray you're dead."
Many patients related pain that was unrelieved with home therapy to require immediate medical attention. The following patient best describes this as "pain not going away and it being like a ten and it gradually gets worse and worse. Everything I take doesn't make it feel better." Another patient states, "when you have problems with aching and it's going on and you feel like it affects your breathing even though you've taken medicine and stuff. That's an emergency, isn't it?" While some patients attempted to remedy the pain at home prior to seeking ED care, many patients came to the ED without trying any over the counter products to cease pain.
Fear of Serious Illness
Though patients may seek emergency care due to the severity or unrelenting nature of their pain, the fear of a serious or life threatening illness propels them to believe their pain is an emergency. An older gentleman relays this with the following statement: "My head was hurting real bad and I know I had high blood pressure and I really wanted to check, because it's real dangerous when you have high blood pressure." When asked if he considered his symptom of headache and history of high blood pressure as an emergency he responded, "yes, a stroke or anything could happen."
Immediate Need for Care
Patients perceived pain very differently but many patients believed pain control should be addressed and treated quickly through the ED. Patients believed they required immediate attention because if their pain was not taken care of "quickly" then the symptoms would only "get worse and worse." The ED is considered the "only place that will relieve pain." One patient with sudden back pain described an emergency as "something that hurts like hell and it needs to be taken care of quickly." While another patient furthered this by saying, "you need to hurry up and go to the doctor, you need to go to the emergency room."
Many patients described a medical emergency as life threatening. This would be anything that would put "someone's life in danger" or if they are "dying." Patients gave many examples of signs and symptoms they considered life threatening to include gun shot wounds, stabbing, stroke, heart attack, loss of consciousness, and broken bones.
Patients perceived an emergency as something "drastic," serious," or "real bad." A patient with a seizure disorder described an emergency as "an injury or you get hurt that you have to be rushed to the hospital. Something dangerous." One patient related his urgency to be something "serious to the point that I can not wait to see a family doctor that day or serious enough for someone to be in tears, they are going to the hospital."
Patients associated a need for quick care or quick service when asked to define a medical emergency. Patients came to the ED believing their sign or symptom was severe enough to need "quick care." For example, patients described an emergency as "something that needs to be treated right away" and "anything that requires needing to see a doctor immediately."
Need for Medical Assistance
The need for immediate medical attention from healthcare professionals emerged from the interviews. Patients believed they needed someone with more medical expertise, therefore, choosing emergency care. Some patients sought emergency care due to their belief that the ED would not "turn them way" because "they are supposed to see you." The following patient provided the best narrative stating "a medical emergency would be something that you can't handle at home and that you would need someone with more experience to help you." Patients who were unable to identify their illness or could not explain their symptoms desired emergency care, as they feared the unknown.
Unable to see Primary Provider
Few patients attempted to contact their PCP to report their illness or medical condition. However, patients claimed if they were unable to contact their PCP, then they would seek emergency care. Patients did relay that the symptoms would have to be "serious" or "hurting and can't go anywhere," in order for them to seek emergency care. However, they believed they needed medical assistance regardless of where the medical care took place.
The purpose of this study was to discover the patient's definition of a medical emergency as such information could facilitate healthcare professionals to understand patient motivation of ED use. Six themes emerged from the research study. Overwhelmingly, patients perceived pain as an emergency. Patients perceived pain differently and have different tolerance levels to pain. Patients believed if severe, unrelenting pain was present, then it was an emergent medical condition. Patients believed they needed the expertise of a healthcare professional to decipher if pain was related to a medical emergency or not. Several patients admitted to not attempting pain remedy with over-the-counter treatments due to patients' lack of medical background or knowledge. Many patients reported they did not take medication due to the fact they were waiting for the ED's advice on which medications to take.
When comparing the patients' definition of a medical emergency to the Emergency Medical Treatment and Labor Act (EMTALA), a similar theme is evident. EMTALA defines a medical emergency as:
"A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part" (Centers for Medicare & Medicaid, 2006).
Patients reported pain and life threatening conditions as an emergency but seem to have a broad, colloquial understanding of a medical emergency as compared to the esoteric definition utilized by EMTALA. Patients perceived an emergency based on their personal understanding of the sign or symptom present. Past experiences and family input influenced their perception of their medical situation, therefore, leading the patient to examine their need for medical care. Patients believed their health was a primary concern and would do what is necessary to resolve their fear of the unknown.
Though EMTALA's definition mentioned pain as a medical emergency it is narrowed to "sufficient" severe pain, not a general, bothersome pain that many ED patients reported. Again, patients have an individual perception of a medical emergency and personal tolerance for pain. Therefore, patients' individualism impacts their decision of what constitutes an emergency.
Many patients believed they should receive quick care if they considered their sign or symptom an emergency, but would become frustrated if they were not seen by the ED provider in what they considered "quick" time. Patients had different perceptions of how timely care should be addressed.
Patient education is needed with a focus on management of chronic disease, preventive heath care, and basic treatment options. Patients need to be knowledgeable of their chronic diseases, therefore, patients may feel comfortable in recognizing health changes and treating basic health needs. Walls, Rhodes, and Kennedy (2002) revealed patients considered the ED as not only a place for illness treatment but also for general and preventive services. The ED is not focused on wellness or preventive care and patients that use the ED as their primary source of healthcare are receiving inappropriate or incomplete care. However, patients should utilize the ED for emergent conditions.
Basic treatment options should be taught in community outreach programs, primary care clinics, and school health education courses. Patients need to be aware of over-the-counter medications such as for treatment of pain, fever, cough and constipation. Also, basic first aid knowledge could prevent or delay an ED visit. For example, if a patient twists their ankle, they could apply an ACE bandage, ice and elevate the ankle at home. A sprained ankle generally requires no immediate professional attention from the ED. While the sprained ankle maybe painful, the patient could take a pro-active approach to control the situation until their PCP is available.
Limitations of the study include the fact that patients were interviewed at three EDs within the same metropolitan city and state. Interviews took place during a one-month period and in the afternoon and late evening, assuming patients had the opportunity to contact a primary provider or urgent care facility. Also, the study was limited to ED patients currently utilizing the ED. Patients' past personal or family experiences in the ED impacted their response to questions. Many friends and family members contributed to patient usage of the ED by encouraging the patient to seek care. Further investigation of family member influence for choosing ED care could be addressed in future research.
This study revealed patients' usage of the ED is driven by their broad and individualistic definition of a medical emergency, which is developed from numerous external sources and experiences. Patients have a broad, colloquial understanding of a medical emergency and perceive an emergency based on their personal understanding of the medical condition present.
Previous research and programs have tried to educate patients on what is an accepted medical emergency and this research study confirmed that the patient's definition of a medical emergency is individualistic. Therefore, this type of education will not change or affect patients' use of the ED if patients perceive their sign or symptom as an emergency. This study discovered many patients sought ED care for healthcare providers' medical expertise and knowledge of treatment options. Patients are not attempting home treatment options such as over-the-counter medications prior to seeking ED care. Basic home treatments should be taught to patients in order to prevent an ED visit or to delay care until their primary provider is available. In addition, patients need to be knowledgeable of their chronic medical conditions in order to attempt home treatment or to recognize symptoms that require immediate care.
Afilalo, J., Marinovich, M., Afilalo, M., Colacone, A., Leger, R., Unger, B., & Giguere, C. 2004. Nonurgent emergency department patient characteristics and barriers to primary care. Acad Emerg Med, 11, 1302-1310.
Billings, J., Parikh, N., & Mijanovich, T. 2000. Emergency department use in New York City: A substitute for primary care? The Commonwealth Fund Issue Brief, March 2000.
Centers for Medicare & Medicaid. Emergency medical treatment & labor act regulations. Retrieved July 13, 2006, from http://cms.hhs.gov/EMTALA.
Cunningham, P.J. 2006. What accounts for differences in the use of hospital emergency departments across U.S. communities? Health Affairs, 25, 324-336.
Davidson, R.A., Giancola, A., Gast, A., Ho, J., & Waddell, R. 2003. Evaluation of access, a primary care program for indigent patients: Inpatient and emergency room utilization. J Community Health, 28, 59-64.
Derlet, R. & Richards, J. 2000. Overcrowding in the nation's emergency departments: Complex causes and disturbing effects. Ann Emerg Med, 35, 63-68.
Franco, S.M., Mitchell, C.K., & Buzon, R.M. 1997. Primary care physician access and gatekeeping: A key to reducing emergency department use. Clinical Pediatrician, 36, 63-68.
Lafrance, M. & Leduc, N. 2002. Prior use of telephone-nursing triage services by patients of emergency services. Rev Epidemiol Sante Publique, 50, 561-570.
McCraig, L.F. & Nawar, E. 2006. National Hospital Ambulatory Medical Care Survey: 2004 Emergency Department Summary. Hyattsville, MD: National Center for Health Statistics.
Powell, D. & Breedlove-Williams, C. 1995. The evaluation of an employee self-care program. Health Values, 19, 17-22.
Ragin, D.F., Hwang, U., Cydulka, R., Holson, D., Haley, L., Richards, C.F., Becker, B.M., & Richardson, L.D. 2005. Reasons for using the emergency department: Results of the EMPATH study. Acad Emerg Med. 12, 1158-1166.
Richardson, D.B. 2006. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust, 184, 213-216.
Shah, M.N., Schmit, J., Croley, W.C., & Meltzer, D. 2003. Continuity of antibiotic therapy in patients admitted from the emergency department. Ann Emerg Med, 42, 117-123.
Sprivulis, P.C., Da Silva, J.A., Jacobs, I.G., Frazer, A., & Jelinek, G.A. 2006. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust, 184, 208-212.
Thomas, D. 2006. A general inductive approach for analyzing qualitative evaluational data. American Journal of Evaluation, 27, 237-246.
Trzeciak, S. & Rivers, E.P. 2003. Emergency department overcrowding in the United States: An emerging threat to patient safety and public health. Emerg Med J, 20, 402-405.
Walls, C.A., Rhodes, K.V., Kennedy, J.J. 2002. The emergency department as usual source of medical care: Estimates from the 1998 national health interview. Acad Emerg Med, 9, 1140-1145.
Young, G.P. & Lowe, R.A. 1997. Adverse outcomes of managed care gatekeeping. Acad Emerg Med, 4, 1129-1136.
Young, G.P., Wagner, M.B., Kellermann, A.L., Ellis, J., & Bouley, D. 1996. Ambulatory visits to hospital emergency departments: patterns and reasons for use. JAMA. 276, 460-465.
Priscilla Pulliam and Jessica Bailey
University of Mississippi Medical Center 2500 North State Street Jackson, MS 39216
Corresponding Author: Priscilla Pulliam firstname.lastname@example.org
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|Author:||Pulliam, Priscilla; Bailey, Jessica|
|Publication:||Journal of the Mississippi Academy of Sciences|
|Date:||Apr 1, 2008|
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