The demand for ED care is at an all-time high, yet the number of EDs continues to decline nationwide. ED overcrowding is a problem with hospitalwide implications. EDs that are at capacity often have patients waiting hours or even days to be fully admitted to a care unit. And every 60 seconds an ambulance is diverted to another facility because of overcrowding, according to the Institute of Medicine.¹

The majority of people seek care in the ED for acute injury or illness. But many people seek care in the ED for acute exacerbations of poorly managed chronic illness, such as diabetes, or for management of a chronic illness in the absence of an acute problem (such as for blood pressure control and cardiac or asthma medication refills). In fact, the ED has become the largest provider of unscheduled primary care visits.²

The roots of the problem

Numerous reasons exist for overcrowding in the ED. Nationwide, EDs are experiencing the impact of the aging U.S. population with the challenges of providing both acute and nonacute chronic care for chronic disorders — a time-consuming and costly venture. Older adults who present to the ED with multiple comorbid disorders, complex medical histories, and polypharmacy represent about 18% of all annual ED visits.³ The Agency for Healthcare Research and Quality estimates that 85% of adults 65 or older have at least one chronic disease, and 62% have two or more chronic diseases, making them a medically vulnerable group.⁴ Elders in long-term care residences and adult congregate living facilities may be inappropriately referred to the ED for chronic care management. This is especially true when the facility employs an attending provider who doesn’t make rounds frequently or doesn’t communicate with staff promptly.² Older adults’ use of the ED is apt to increase since the population of people over age 65 will more than double by 2030.⁵

Compounding the problem for EDs are people who are homeless, people with substance abuse problems, patients mistrustful of primary care providers, low-income families, and uninsured or underinsured children. EDs have rapidly become a safety net for medically indigent, uninsured, and underinsured patients alike.²

Even though healthcare resources for chronic care management may be available in the community, many homeless people do not access them because of social, economic, and psychological barriers. Substance abuse often exacerbates the problem. Seasonal weather changes have also been shown to increase care-seeking among people who are homeless.⁶

Low income is another factor leading to inappropriate use of the ED for chronic illness management. Public safety-net hospitals are disproportionately affected by indigent and uninsured chronically ill people seeking primary care for chronic diseases.^7,8 These patients are often sicker than the general patient population and delay seeking care because they cannot afford medications, healthcare visits, or prescribed diets.⁷ They are more likely to be from ethnic minorities and groups with HIV, mental health conditions, or substance abuse problems.^8,9 Coordinating care and providing patient education may be difficult when patients at public safety-net hospitals do not use English as their primary language.⁹

Some patients, usually younger adults or caregivers of children, seek ED treatment because they mistrust traditional primary healthcare services.¹⁰ Unfortunately, the lack of an established, trusting caregiver relationship limits the possibility that evidence-based practice guidelines are being followed for chronic disease management.

Primary care providers’ limited office hours may also contribute to ED overcrowding. Patients may face difficulties in getting a prompt appointment. Primary care providers who lack the resources in their offices to care for a patient may refer the patient to the ED for management of a chronic problem.¹⁰

What’s the difference?

Patients and caregivers alike often cannot differentiate a chronic problem from an acute complaint that warrants emergency care. Examples of acute conditions or injuries include acute MI, appendicitis, lacerations, fractures, sepsis, seizures, and acute bronchitis or pneumonia. Chronic conditions include CHF, asthma, diabetes, chronic back pain, and substance abuse.

Common and chronic

CHF — We are in the midst of a heart failure epidemic. This progressive disorder causes severe debility and death, often within the first five years of diagnosis.¹¹ Exacerbations can be brought on by inadequate lifestyle measures, such as poor dietary choices and nonadherence with medication.¹¹ A significant percent of repeat hospitalizations for CHF management are related to medication and dietary nonadherence.¹¹ Some patients may not be able to afford their medications, making adherence difficult. Case management and referral to community and other sources may be useful.

Asthma — At least 21.3 million Americans have asthma.¹² Hispanics and African Americans are disproportionately affected by asthma and have poorer outcomes than members of other ethnic groups.¹² Asthma is a chronic disease that can be self-managed with success. When asthma is poorly managed, the use of resources, including ED care, escalates. To reduce the need to manage asthma in the ED, nurses can incorporate education into the plan of care on smoking cessation, avoidance of triggers (such as passive smoke), adherence with medications, flu vaccination, and the proper use of peak-flow meters to monitor status.¹³ When possible, have patients perform a return demonstration of the correct use of inhalers and peak-flow meters.

Chronic back pain — With a lifetime prevalence as high as 80%, low back pain is a chronic condition with acute exacerbations that lead many people to seek emergency care.¹⁴ In the absence of certain red-flag conditions — including cauda equina syndrome (a disorder affecting the bundle of nerve roots), vertebral fractures, tumors, infections, or serious nonspinal conditions — ED physicians are more likely to recommend inactivity and prescribe a short course of opioids for pain relief than to order diagnostic studies. Community-based providers are more likely to use highly effective therapeutic modalities, including transcutaneous electrical nerve stimulation (TENS), traction, trigger point injections, and physical therapy.¹⁴ Patients often think that the ED is the ideal place to receive a thorough diagnostic evaluation and definitive diagnosis. This is, quite often, simply not true.

Substance abuse — Patients with substance use disorders are often heavy users of EDs because they lack established primary care providers in the community, even though they experience medical problems more often than the general public. These patients face many barriers that affect their care choices, including lifestyle disorganization, a lack of insurance, and negative interactions with mainstream health care. They often seek care only in response to a crisis or as a last resort.¹⁵

When recognized early, chronic conditions can be managed in the primary care setting, which averts the need for acute emergency care. Success in caring for chronic conditions in the primary care setting relies heavily on proper medical management and the education of patients and caregivers.

Cost differences

EDs are the most expensive source of healthcare services for patients. The relationship between financial obligation and care-seeking behaviors is difficult to pinpoint, but some people will avoid seeking care, fearing an inability to pay will damage their creditworthiness.

In one study, patients who were not able to correctly state their copayments for ED care (59% of patients surveyed) were more likely to use the ED. Among the 41% who were aware of their copyaments, those with higher copayments sought care at sites other than the ED, called their primary care providers or contacted them via the Internet, delayed going to the ED, or didn’t seek treatment at all.^16,17

While copayments may delay or deter people with healthcare coverage from seeking ED care for chronic complaints, the same is not true for the uninsured. They may seek treatment at safety-net EDs, where care for the indigent is likely to be written off.

ED vs. primary care

The ED environment often doesn’t give nursing staff enough time to adequately teach patients how to better care for their chronic diseases. But patients in the ED may actually require more time for patient education. Surprisingly, the lower a person ranks his or her perceived health status, the more likely the person is to delay seeking care, especially for acute illness associated with chronic diseases, and end up in the ED.¹⁷

Care in EDs is typically provided by different staff members at each visit, removing the possibility for continuity of care for chronic conditions using evidence-based practice guidelines. But as important as a therapeutic relationship with a primary care provider is, many patients and caregivers place more value on other things. For example, in one study of parents seeking health care for their children, nearly 60% ranked a shorter wait time as more important than seeing the same physician at each visit.¹⁸ One-third of the parents reported they lacked regular physicians for their children and used the ED for routine care. Even parents reporting an established non-ED provider relationship said they were more likely to visit their providers for well visits and to visit the ED for illness care.¹⁸

People who routinely seek care in the ED are the “frequent flyers,” and repeated encounters with them may lead stressed healthcare workers to make dangerous assumptions. When a patient has had a pattern of exaggerating symptoms or seeking ED care for chronic conditions, clinicians may conclude that the patient is crying wolf.⁸ However, studies have shown that the frequent flyer population is as sick as or sicker than the general population who seeks ED care.¹⁹

One potential positive exists with repeat visits: If a patient receives care from the same nurse, a trusting relationship may develop in which the nurse may be more likely to persuade the patient to engage in health-promotion behaviors.8 The education the nurse provides while the patient is symptomatic may be more effective in changing lifestyle behaviors that lead to negative consequences.¹¹

Some patients and their caregivers report seeking care for nonurgent complaints in EDs because they simply do not want to wait for care.²⁰ Some patients lack transportation, and others experience restricted access to specialists and view the ED as a quick solution to their problem.¹⁰ A sense of loneliness or isolation may also be a driving factor behind some ED visits for chronic care patients.¹³

Nurses can become frustrated by people with nonurgent chronic complaints who demand their attention. Nurses may view these patients as a burden that contributes to overcrowding, thus diverting resources and efforts away from patients with life-threatening problems.¹⁰

Often it boils down to the fact that many patients simply don’t understand what EDs are for. Other patients are quite savvy, realizing that the Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals to assess, treat, and stabilize all patients before transfer or discharge regardless of patients’ ability to pay.²

Negative feelings occur not only among emergency care providers. Patients seeking ED care for chronic conditions may feel guilty for “bothering” the physician or ED staff with a nonacute complaint.¹³

Refocusing the focus

The primary focus of the healthcare system over the past several decades has been acute exacerbations of chronic illnesses, for example, a patient with poorly controlled asthma who requires frequent ED care or a patient with underlying CHF who does not follow dietary restrictions, resulting in pulmonary edema. This focus must be redesigned to meet the needs of the growing population of chronically ill people.²⁰

Chronic healthcare problems need disease-specific chronic management programs. People with chronic diseases need to be taught how to self-manage multiple aspects of their care, including diet, medications, physical activity, and specific treatments. ED employees simply do not have enough time to provide this necessary education.²⁰ Relying on the ED for management of chronic health problems may actually compound the problems.

Traditional case management efforts try to triage patients to settings other than the ED or to methods of self-care. But the ability of traditional case management to reduce inappropriate ED visits has been minimal, at best.⁸

The increased use of nurse practitioners and physician assistants may help deal with a surplus of ED patients.^20,21 But additional staff may be a temporary stress reliever, not a permanent solution.

What can be done?

To reduce the inappropriate use of the ED, staff must be aware of resources in the community for educational, social, and spiritual support. ED staff could revise discharge instructions for patients with chronic disease complaints to incorporate wellness promotion and referrals to community programs or services. Staff can compile an easily accessible reference sheet or patient handout for community resources. Referrals can include community senior services, the Area Agency on Aging, the Red Cross, health clinics, and religious and civic organizations.⁸

A patient’s inability to afford medications may make the management of a chronic disease more difficult. ED staff can refer patients to sources of free or reduced-cost medications. For a listing of resources, see Nursing Spectrum’s CE on financial triage: www.nurse.com/ce/syllabus.html?CCID=3395.

Patients must be taught how to participate in their own care. They need to understand the nature of their disease, the rationale for treatments, and the importance of adhering to a medical regimen.¹³

Patient education can incorporate technology through telephone triage, the Internet, and self-management programs tracked through databases that gauge markers of improvement, such as blood glucose levels in diabetes and weight in CHF.²⁰ Telephone triage systems that rely on disease-specific management protocols have proven effective in guiding patients to appropriate care settings.^13,22

Another helpful measure could be to require nurses to learn ED nurse competencies involving promoting preventive care measures in community settings. The education programs could include the key management criteria of the chronic diseases for which patients inappropriately seek ED care. Central to the program must be the concept that continuity of care with one provider promotes wellness and the early detection of illness, especially among people with chronic illness.

Measures aimed at improving self-management of chronic diseases have the potential to improve patient outcomes and reduce ED caregivers’ stress and frustration.³ Changes must take into account the cultural, behavioral, and professional adjustments to encourage improvement in the healthcare system.¹³

The number of people with chronic diseases is expected to dramatically increase, posing a dilemma for EDs already pushed to the limits.

Care coordination that includes evidence-based, patient-centered care focusing on underlying health-promoting behaviors and knowledge deficits is crucial to reducing inappropriate ED visits.

Nurses must look beyond the problems of deliberate abuse or ignorance on the part of patients. Instead, the inappropriate use of EDs may be viewed as a failure of the healthcare system to provide accessible alternatives and preventive education. The goal is to teach patients to seek the right care in the right place at the right time. When patients gain control of their chronic diseases, they become empowered to recognize, treat, and manage their illnesses on a daily basis.²³