Do patients use minor injury units appropriately?

Journal of Public Health Medicine Vol. 18, No. 2, pp. 152-156 Printed in Great Britain Do patients use minor injury units appropriately? Jeremy Dale and Brian Dolan Abstract Background This study aimed to examine the extent to which patients make appropriate use of Accident and Emergency and Minor Injury Unit services. The outcomes used included the proportion of Minor Injury Unit patients referred to an Accident and Emergency department, comparison between the proportions admitted from patients attending Minor Injury Units and Accident and Emergency departments directly, and the diagnoses and lengths of stay of those requiring admissions from Minor Injury Units. Methods Patients were identified who were resident in the vicinity of Deal and Folkestone and in January 1994 attended local Minor Injury Units in these towns or nearby Accident and Emergency departments at times when the Minor Injury Units were open. The following details were documented from their hospital notes: presenting problem, time and date of attendance, mode of arrival at/referral to the facility, postcode of residence, age, sex, diagnosis and referral/discharge. A sub-sample of 448 patients were interviewed while waiting to be seen at the Minor Injury Units. Results The criteria for inclusion in the study were met by 1891 patients. Of these, 188 (99 per cent) were referred by a general practitioner (GP). A total of 1472 patients attended the Minor Injury Units without referral from a GP, of whom 28 [1-9 per cent; 95 per cent confidence interval (Cl) 1-2-2-6 per cent] were referred for further assessment and care to a general hospital. Whereas 71 (29 5 per cent; 95 per cent Cl 23-7-35-3 per cent) of the 241 who went directly to an Accident and Emergency department without GP referral required admission, this was true for only eight (0-5 per cent; 95 per cent Cl 0-2-0-9 per cent) self-referred patients attending Minor Injury Units. Four of the latter admissions were for trauma-related problems and required stays of less than 24 hours. Of the patients attending the Deal and Folkestone Minor Injury Units who were interviewed, only 195 (470 per cent) said that they would have attended an Accident and Emergency department had the facility not been available; the remainder said that they would have either gone to their own G P or self treated. The latter were more likely to be female patients, to have problems of longer duration, and/or to have attended the facilities by public transport or taxi. Conclusion The results support the view that patients choose appropriately between attending a Minor Injury Unit or an Accident and Emergency department. However, there was evidence that the availability of an intermediate tier of health care for minor injuries appears likely to result in increased overall workload. This small-scale study leaves unanswered questions in terms of clinical outcomes and the quality of care provided by different facilities. Keywords: Minor Injury Units, A&E attenders, appropriateness of attendance Introduction Increasing numbers of Minor Injury Units are being established throughout the country. 1 These facilities provide an open access minor injury service for patients not requiring the specialist investigative and support services of an acute general hospital. They may be staffed by nurse practitioners 2 ' 3 and/or general practitioners (GPs), and provide a service that overlaps with the work of Accident and Emergency departments and GPs. 1 There is usually access to radiological investigations, in addition to emergency laboratory investigations at times when such services are available within the hospital. Emergency ambulances are not permitted to deliver patients to Minor Injury Units. There remains lack of agreement on what constitutes a Minor Injury Unit in terms of the basic range of services that should be provided. The Department of Health is currently reviewing the way it defines facilities providing emergency care (D. Gilbert, Special Clinical Services, DoH, personal communication, 1995). The trend towards rationalizing Accident and Emergency services onto fewer sites threatens the provision of locally available services. Minor Injury Units may fulfil a useful role in maintaining accessibility for local communities. They appear to be highly Department of General Practice and Primary Care, and Department of Accident and Emergency Medicine, King's College School of Medicine and Dentistry, London SE5 9PJ. JEREMY DALE, Senior Lecturer (Hon. Consultant) in Primary Care BRIAN DOLAN, Clinical Researcher Address correspondence to Dr J. Dale. Oxford University Press 1996

valued by their local populations. 4 ' 5 However, concern has been voiced, particularly by some members of the Accident and Emergency profession, that patients may misjudge their needs and so inadvertently delay receiving care requiring specialist skills and resources. 6 " 8 The current study was undertaken as part of a larger appraisal of minor injury services commissioned by Kent Family Health Services Authority (FHSA). 4 ' 9 The aim of the study was to examine the extent to which patients make appropriate use of Accident and Emergency and Minor Injury Unit services. Two Minor Injury Units and three neighbouring Accident and Emergency departments were studied. The hours of opening of the Minor Injury Units were 9 a.m.- 6 p.m. and 8 a.m. 6 p.m. (weekdays and weekends) for the Folkestone and Deal services, respectively. The staffing of both units included local GPs working as clinical assistants who treated all patients attending with new problems. Data were collected on all patients attending the Minor Injury Units, on those referred from the Minor Injury Units to Accident and Emergency departments, and on patients directly attending the Accident and Emergency departments from the districts served by the Minor Injury Units. The outcomes used to determine appropriateness included the proportion of Minor Injury Unit patients subsequently referred to an Accident and Emergency department, comparison between the proportion admitted from those directly attending an Accident and Emergency department with those who first attended a Minor Injury Unit, and the diagnoses and lengths of stay of patients requiring admission who had first attended a Minor Injury Unit. In addition, as part of a study of users' perceptions of the service a sub-sample of patients attending the two facilities during the study period were asked about USE OF MINOR INJURY UNITS 153 where they would have sought health care had the Minor Injury service not been available. Method Data were collected in two ways. First, from hospital attendance registers patients were identified who were resident in the vicinity of Deal and Folkestone (CT14, CT19 and CT20 postal districts) and in January 1994 had attended Minor Injury Units in these towns or nearby Accident and Emergency departments at Ashford (Kent), Canterbury or Dover at times when the Minor Injury Units were open. Those attending with new problems had their records retrieved. The following details were documented from case notes: presenting problem, time and date of attendance, mode of arrival, postcode of residence, age, sex, diagnosis and referral/discharge. Second, during the study period 448 patients at the Minor Injury Units were interviewed while waiting to see the doctor. Full details of the method of sampling and the interview schedule have been described elsewhere. 9 Results The outcome of hospital attendance During January 1994, 1891 patients resident in the CT14, CT19 and CT20 postal districts presented a new problem at one of the Minor Injury Units or Accident and Emergency departments included in the study. Of these, 188 (9-9 per cent) were referred by a GP. Of the 856 patients attending Folkestone Minor Injury Unit without referral from a GP, 17 (20 per cent) were referred for further assessment and care to one of the three neighbouring Accident and Emergency departments. For those attending the Deal Minor TABLE 1 Total numbers (with percentages given in parentheses) of patients (excluding referrals from GPs) attending Minor Injury Units and Accident and Emergency departments, with postal codes of residence in Folkestone and Deal, at times when the Minor Injury Units were open Attendances in January 1994 Attenders requiring admission Minor Injury Units Folkestone Deal Total Accident and Emergency departments Ashford (Kent) Canterbury Dover Total 856 616 1472 147 32 62 241 6 (0-7) 2 (0-3) 8 (0-5) 50 (340) 2 (6-3) 19(30-6) 71 (29-5)

154 JOURNAL OF PUBLIC HEALTH MEDICINE TABLE 2 Patients requiring acute hospital admission who were referred from a Minor Injury Unit to an Accident and Emergency department Age (years) Sex Admitting specialty Diagnosis Admission duration 10 59 25 21 71 16 41 <1 Paediatrics Medical Surgical Medical Orthopaedics Surgical Orthopaedics Paediatrics Head injury/concussion Chest pain Acute pancreatitis Pneumothorax Fractured wrist, manipulation required Facial/chest injury/assault?rib fracture Compound fracture of finger Irritable?diagnosis Injury Unit, this occurred for 11 (1-8 per cent) of the 616 non-gp referred patients. A further 330 patients with Deal or Folkestone postal codes attended one of the three Accident and Emergency departments at times when the Minor Injury Units in Deal and Folkestone were open. Of these patients, 89 (270 per cent) were referred by a GP. Of the remainder, 67 (27-8 per cent) attended by emergency '999' ambulance and 174 (72-2 per cent) by private or public transport. Many of the latter, it appeared, had been working, shopping or travelling in the vicinity of Ashford, Canterbury or Dover at the time when they decided to attend the Accident and Emergency department. Of the 1713 patients attending a Minor Injury Unit or an Accident and Emergency department without referral by a GP, 79 (4-6 per cent) required admission at one of the three district hospitals (Table 1). Of these patients, 71 (89-9 per cent) had referred themselves directly to an Accident and Emergency department; 31 (39-2 per cent) arriving by emergency ambulance and 40 (50-6 per cent) by private or public transport. Eight (10-1 per cent) patients had been referred from a Minor Injury Unit (Table 2). Minor Injury Unit patients' perceptions of the need for hospital care Of the 415 patients attending the Deal and Folkestone units who answered the question 'If there was no Minor Injury Unit available, what would you have done?' only 195 (470 per cent) said that they would have attended an Accident and Emergency department; the remainder said that they would have either gone to their own GP or self treated. Those who stated that they would have attended an Accident and Emergency department were more likely to be male, to have problems of shorter duration, and to have attended the Minor Injury Unit by private car (Table 3). TABLE 3 Numbers (with percentages given in parentheses) of patients at the Minor Injury Units who would have attended an Accident and Emergency department if the local facility was not available, by sex, duration of problem and mode of transportation to the unit Gone to A&E Not gone to A&E (n = 220) df Sex 116 (60-4) 76 (39-6) 96 (44-4) 120(55-6) 10-4 1 0002 Duration of problem < 6 hours 6-24 hours 1-7 days > 1 week 80(410) 50 (25-6) 41 (21 0) 24(12-3) 57 (260) 64 (29-2) 63 (28-8) 35(16-0) 10-9 0012 Mode of transport to Minor Injury Unit Private car 149 (76-4) 137(62-2) 90 1 0004

Discussion The results from this study lend support to the view that patients choose appropriately between attending a Minor Injury Unit or an Accident and Emergency department. Altogether, 1-9 per cent [95 per cent confidence interval (CI) 1-2-2-6 per cent] of the patients attending the Minor Injury Units required referral to an Accident and Emergency department. Whereas 29-5 per cent (95 per cent CI 23-7-35-3 per cent) of those who went directly to an Accident and Emergency department required admission, this was only true for 8 (0-5 per cent; 95 per cent CI 0-2-0-9 per cent) patients attending a Minor Injury Unit. As shown in Table 2, only 4 (0-3 per cent) of the 1472 patients who selfreferred to a Minor Injury Unit were admitted to hospital for longer than 24 hours duration. In considering the applicability of these results to other settings, it is important to note that both Minor Injury Units employed local GPs as clinical assistants. There is some evidence to suggest that nurse practitioner run facilities refer a larger proportion of patients for Accident and Emergency department assessment than was identified in this study. For example, at St Charles' Hospital in West London the nurse run Minor Injury Unit refers about 10 per cent of attenders to an Accident and Emergency department. 3 This study only looked at attendances during January 1994. However, the workload at the Minor Injury Units studied varies throughout the year, reflecting seasonal variation in the populations served (both units receive large numbers of tourists and foreign language students during the summer months) as well as variations in the patterns of injury that occur. At the Folkestone Minor Injury Unit, for example, the monthly attendance rates in 1993 varied from 825 new attenders in December to 1216 patients in July. 9 It is possible that the proportion of patients referred on to Accident and Emergency departments might also show seasonal variation. The impact that attending a Minor Injury Unit has on clinical outcome needs further study. Although there is clearly a possibility that attending a Minor Injury Unit may have a detrimental effect on the patient's clinical outcome through delaying access to specialist care, conversely the initial assessment and care patients receive at an accessible, local facility might often be a beneficial factor. It is also possible that some of the patients who were discharged home from the Minor Injury Unit should have been referred to an Accident and Emergency department for further care, and experienced negative outcomes as a result. It was beyond the scope of the current study to determine the extent to which attending a Minor USE OF MINOR INJURY UNITS 155 Injury Unit adversely or favourably influences health status. Using admissions as an outcome measure of appropriateness clearly has its limitations, as the decision to admit a patient is known to reflect aspects of both the patient's presentation and the doctor's experience and approach. There is evidence that junior medical staff working in Accident and Emergency departments have a lower threshold than GPs for referring patients for investigations and to specialist teams; this may lead to some unnecessary admissions. 10 Psychosocial factors often accompany, or may lead to, patients' attendance at an Accident and Emergency department, 11 ' 12 and failing to recognize and respond to these concerns, expectations and beliefs may lead to inappropriate interventions or ineffective care. A larger-scale study would be required to identify the extent to which patients attending the Accident and Emergency departments without GP referral could appropriately be managed in either a Minor Injury Unit or general practice. Attendance at Accident and Emergency departments is recognized as strongly correlating with the patients' geographical distance from the department. l3 ~ 15 In this study, attendance at an Accident and Emergency department was confounded by processes involved in decision-making related to contacting the emergency services for help. Emergency ambulances do not transport patients to the Minor Injury Units studied and so the determinants of whether patients attended an Accident and Emergency department or a Minor Injury Unit included whether or not the emergency services had been contacted. Not all the self-referred patients who attended the Minor Injury Units would have used an Accident and Emergency department had the Minor Injury Unit service not been available. Approximately half would have either gone to their own GP or self treated; these were more likely to be patients who were female, had attended the facility by public transport or taxi, and/or had problems of longer duration. This suggests that the availability of an intermediate tier of health care in these environments may be contributing to an increased overall workload for the health service, but this needs to be balanced against potential unmet need that might result were these facilities not present. The overall impact of altering local access to minor injury care needs further study. In conclusion, although these findings support the view that patients use Minor Injury Units appropriately, the limitations of the measures of appropriateness used in this study need to be acknowledged. They leave unanswered questions in terms of clinical outcomes and the quality of care provided by such

156 JOURNAL OF PUBLIC HEALTH MEDICINE facilities. Given that Minor Injury Units vary greatly in staffing, activity and populations served, a multi-centre study is needed to address these issues definitively. This would allow comparative assessment of different models of care, including their cost effectiveness. Acknowledgements We thank Linda Tyson, Caroline Grenfell and the staff at all five hospitals who assisted with data collection. References NHSME. A study of minor injury services. Leeds: Department of Health, 1994. 2 Jones G. Minor injury in the community. Nursing Standard 1993; 7(22): 35-36. 3 Baker B. Model methods. Nursing Times 1993, 89(47): 33-35. 4 Dale J, Dolan B. Cut and thrust. Health Serv J 1994; 104(5406): 26-27. 5 Garnett SM, Elton PJ. A treatment service for minor injuries: maintaining equity of access. Public Hlth Med 1991; 13: 260-266. 6 British Association for Accident and Emergency Medicine. Response to 'Review of Minor Injury Services, NHSME' (letter). London: BAEM, 1993. 7 Porter J (A&E Clinical Director, Southend Health Care Trust), quoted in Health Serv J. Minor Injuries Units are 'a dangerous con'. 1 December 1994; 4. 8 Miles S (Hon. Secretary, British Association for Accident and Emergency Medicine), quoted in Doctor. Fear of sanction threat to A&E. 20 July 1995; 3. 9 Dale J, Dolan B, Lang H. Healthcare in Folkestone and Deal: new directions for the Minor Injury Units. London: King's Accident and Emergency Primary Care Service and Kent FHSA, 1994. 10 Dale J, Green J, Reid F, Glucksman E, Higgs R. Primary care in the Accident and Emergency department: II. Comparison of general practitioners and hospital doctors. Br Med J 1995; 311: 427-430. " Salkovskis PM, Storer D, Atha C, Warwick HMC. Psychiatric morbidity in an accident and emergency department: characteristics of patients at presentation and one month follow-up. Br J Psychiat 1990; 156:483-487. 12 Olsson M, Edhag O Rosenqvist U. Emergency care: identification of psychosocial problems. Scand J Social Med 1986; 14: 87-91. 13 McKee C, Gleadhill D, Watson J. Accident and emergency attendance rates: variation among patients from different general practices. Br J Gen Pract 1990; 40: 150-153. 14 Ingram DR, Clarke D, Murdie RA. Distance and decision to visit an emergency department. Social Sci Med 1978; 12: 55-62. 15 Magnusson G The role of proximity in the use of hospital emergency departments. Sociol Hlth Illness 1980; 2: 202-214. Accepted on 31 October 1995