Journal of Modern Medical

Introduction
The emergency department (ED) of hospitals, as one of the most crowded hospital departments, is at the forefront of receiving and treating critically ill and injured patients any time, day or night. The triage process, which is the first step in dealing with patients in EDs, prioritizes patients and categorizes them according to the severity of their clinical conditions. The studies in Iran have shown that 20-60% of the patients refer to the EDs due to urgent and uncomplicated problems that can be treated immediately and effectively in lower-level medical centers. Considering that the referral of non-emergency cases to the EDs are increasing day by day, and the hospitals in Iran often receive a high number of patients to their EDs  (due to lower costs and the transfer by ambulances), and given that there is a lack of manpower and facilities in the EDs of hospitals in Iran, and no study has been conducted in Golestan province on the number of non-urgent ED visits, this study aims to determine the burden of non-urgent visits to the EDs of public hospitals in Golestan, Iran. 

Methods
This is a descriptive cross-sectional study. The study population includes all patients referred to the ED of public hospitals affiliated to Golestan University of Medical Sciences in 2019, and visited by a physician. Patients who were not in urgent need for emergency care and were in the fourth and fifth levels of triage were considered as non-urgent patients. The information related to patients’ ED visits was obtained from the hospital information system and saved in an Excel file. The census sampling method was used in this study. The services received by the patient were also investigated by visiting one of the hospitals in person. Also, using the hospital information system and the top-down costing method, service costs were extracted. The data were analyzed after correction. To describe the data, descriptive statistics were used in SPSS software, version 23.

Results
In this study, 42% of ED visits were identified as non-urgent visits. Of these, 200,161 patients (90.8%) were triaged as the level 4 and 20,255 patients (9.2%) as the level 5. Furthermore, 78,269 patients (43%) were male and 103,988 patients (57%) were female. The mean age of the patients in overall was 30.19±19.96 year; 29.48±20.29 years for males, and 30.73±19.69 years for females. Almost all patients with level 5 triage received the ED services. The patients with level-4 triage, in addition to the emergency care, received services related to injections, medicines, and laboratory tests. The average cost for each patient with level 5 triage, according to the tariffs in 2019, was 127,000 Iranian Rials. For the patients at level 4, the average cost was estimated at 250,000 Iranian Rials. By multiplying the average cost of each patient by the total number of patients with levels 4 and 5, the total cost for each level was obtained. The total cost of non-urgent visits to the ED of public hospitals in 2019 was 43,856,887,000 Iranian Rials.

Conclusion
According to the findings, the burden of non-urgent visits to the EDs of public hospitals in Golestan, Iran in 2019 was 42%, which is considerable. It is necessary for the officials of Golestan University of Medical Sciences to pay attention to the causes of non-urgent ED visits and find solutions. According to the results, the total cost of non-urgent ED visits was 43,856,887,000 Iranian Rials. Having more accurate and comprehensive information about the patients who visit the EDs can provide more practical solutions to reduce admissions to the EDs. Unnecessary referrals of patients to the ED of hospitals can cause a waste of hospital resources. Therefore, policymakers and managers of the health system in Iran should change the method of payment to hospitals and physicians, create and strengthen a committee for the utilization of hospital resources, increase the home visits and the follow-up of patient care, and apply quality management measures to reduce the patients’ unnecessary ED visits, which can lead to improving the quality of hospital services.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of Golestan University of Medical Sciences (Code: IR.GOUMS.REC.1399.126).

Funding
This article was extracted from a research project, funded by Golestan University of Medical Sciences (Grant NO.:111380).

Authors' contributions
Conceptualization: Mohammad Javad Kabir and Alireza Heidari; Methodology and data analysis: Zahra Khatirnamani and Sajad Moeini; Data collection: Sakineh Beigom Kazemi and Amirhossein Rahimi; Data entry: Zahra Khatirnamani, Sajad Moeini; Writing the original draft: Alireza Heidari; Review: Mohammad Javad Kabir and Abbas Badakhshan; Final approval: All authors.

Conflicts of interest
The authors declared no conflicts of interests.

Acknowledgements
The authors would like to express their gratitude to the Deputy for Research of Golestan University of Medical Sciences and the nurses of hospitals who had cooperation in this study.

 

References

1. Konateke S, Yılmaz M. Turkish validity and reliability study of the brief emergency department patient satisfaction scale. Int Emerg Nurs. 2022; 61:101145. [DOI:10.1016/j.ienj.2022.101145] [PMID]
2. Farley H, Enguidanos ER, Coletti CM, Honigman L, Mazzeo A, Pinson TB, et al. Patient satisfaction surveys and quality of care: An information paper. Ann Emerg Med. 2014; 64(4):351-7. [DOI:10.1016/j.annemergmed.2014.02.021] [PMID]
3. Makary MA, Daniel M. Medical error-The third leading cause of death in the US. BMJ. 2016; 353:i2139. [DOI:10.1136/bmj.i2139] [PMID]
4. Pourasghar F, Sadegh Tabrizi J, Ala A, Daemi A. [Developing intelligent electronic triage system using the emergency severity index (Persian)]. Health Inf Manag. 2014; 11(5):537-47. [Link]
5. Khazaei A, Khatiban M, Saeidi SZ, Karamporian A, Soltanian AR, KimiaieAsadi H, et al. [Evaluation of factors affecting emergency department length of stay (Persian)]. Avicenna J Nurs Midwifery Care. 2015; 23(3):62 -71. [Link]
6. Kahouei M, Eskrootchi R, Ebadi Fard Azar F, Abol Hassani H. [Triage staff expectations data model: Hospital emergency information system (Persian)]. Health Inf Manag. 2013; 10(3):1-12. [Link]
7. Esmailian M, Talebpoor M, Mehrabi-Koushki A. [Frequency distribution of re-hospitalization and related factors in patients discharged in 12 hours from Alzahra Hospital Emergency Service, Isfahan, Iran during 2015 spring and summer (Persian)]. J Isfahan Med Sch. 2016; 34(371):98-105. [Link]
8. Northington WE, Brice JH, Zou B. Use of an emergency department by nonurgent patients. Am J Emerg Med. 2005; 23(2):131-7. [DOI:10.1016/j.ajem.2004.05.006] [PMID]
9. Guttman N, Zimmerman DR, Nelson MS. The many faces of access: Reasons for medically nonurgent emergency department visits. J Health Polit Policy Law. 2003; 28(6):1089-120. [DOI:10.1215/03616878-28-6-1089] [PMID]
10. Pitts SR, Niska RW, Xu J, Burt CW. National hospital ambulatory medical care survey: 2006 emergency department summary. Natl Health Stat Report. 2008; (7):1-38. [PMID]
11. Haghdoost Z, Safavi M, Yahyavi H. [Effect of triage education on knowledge, attitude and practice of nurses in poursina educational and therapeutic emergency center in Rasht (Persian)]. J Holist Nurs Midwifery. 2010; 20:14-21. [Link]
12. Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Aff. 2010; 29(9):1630-6. [DOI:10.1377/hlthaff.2009.0748] [PMID] [PMCID]
13. Uscher-Pines L, Pines J, Kellermann A, Gillen E, Mehrotra A. Emergency department visits for nonurgent conditions: Systematic literature review. Am J Manag Care. 2013; 19(1):47-59. [PMID] [PMCID]
14. Bozorgi F, Lali A, Hosseini Nejad SM, Amini Ahidashti H, Mahdavi M, Fallah R. [Rapidity of emergency services and associated factors in Sari Imam Khomeini Educational Hospital (Persian)]. J Mazandaran Univ Med Sci. 2014; 24(114):17-25. [Link]
15. Numanoğlu Teki̇ R, Şahin B. Comparison of top down and bottom up cost approaches in colon and rectal cancer treatment. Health. 2021; 13(2):90-109. [DOI:10.4236/health.2021.132009]
16. Dolatabadi AA, Shahrami A, Amini A, Alimohammadi H, Maleki M. [Evaluation of non-emergency cases using emergency department services (Persian)]. Iran J Emerg Med. 2017; 4(3):91-6. [Link]
17. Benahmed N, Laokri S, Zhang WH, Verhaeghe N, Trybou J, Cohen L, et al. Determinants of nonurgent use of the emergency department for pediatric patients in 12 hospitals in Belgium. Eur J Pediatr. 2012; 171(12):1829-37. [DOI:10.1007/s00431-012-1853-y] [PMID]
18. Gulacti U, Lok U, Celik M, Aktas N, Polat H. The ED use and non-urgent visits of elderly patients. Turk J Emerg Med. 2016; 16(4):141-5. [DOI:10.1016/j.tjem.2016.08.004] [PMID] [PMCID]
19. Bahadori M, Mousavi SM, Teymourzadeh E, Ravangard R. Emergency department visits for non-urgent conditions in Iran: A cross-sectional study. BMJ Open. 2019; 9(10):e030927. [DOI:10.1136/bmjopen-2019-030927] [PMID] [PMCID]
20. Zarei G, Zarei T, Pourghadimi S. [Untimarketing the unnecessary use of health services on social security organization (Persian)]. J Healthc Manag. 2019; 2(10):23-33. [Link]
21. Rivers EP, Nguyen HB, Huang DT, Donnino MW. Critical care and emergency medicine. Curr Opin Crit Care. 2002; 8(6):600-6. [DOI:10.1097/00075198-200212000-00020] [PMID]
22. Capp R, Rosenthal MS, Desai MM, Kelley L, Borgstrom C, Cobbs-Lomax DL, et al. Characteristics of medicaid enrollees with frequent ED use. Am J Emerg Med. 2013; 31(9):1333-7. [DOI:10.1016/j.ajem.2013.05.050] [PMID]
23. Barbadoro P, Di Tondo E, Menditto VG, Pennacchietti L, Regnicoli F, Di Stanislao F, et al. Emergency department non-urgent visits and hospital readmissions are associated with different socio-economic variables in Italy. Plos One. 2015; 10(6):e0127823. [DOI:10.1371/journal.pone.0127823] [PMID] [PMCID]
24. Rahiminezhad A, Bagherpour M, Erjaie A, Sepehri M. [Developing the human resources costing method depending on time-driven activity (a case study: Bu-Ali Sina Hospital, the emergency ward, Tehran) (Persian)]. J Health Account. 2014; 3(2):63-76. [DOI:10.30476/jha.2014.16980]
25. Dolatabadi AA, Maleki M, Memary E, Kariman H, Shojaee M, Baratloo A. The use of emergency department services for non-emergency conditions. Health Med. 2017; 11(1):1-3. [Link]
26. Shams L, Pajooman E. [Efficacy of family physician program in providing primary care in Talesh, Iran (Persian)]. J Guilan Univ Med Sci. 2022; 31(1):18-27. [DOI:10.32598/JGUMS.31.1.1760.1]