Increasing demand for emergency patient services: underlying drivers,implications and potential solutions

The rise in demand for emergency patient services is a significant issue for the health system. The ever increasing burden on emergency transportation services, emergency departments (EDs) and acute hospitals has implications for resourcing and the quality of care delivered. Governments and service providers have responded with various strategies, however demand for emergency
healthcare continues to rise. Ageing of the population is also an important issue for health service planning.
Reviews of the international and national literature of trends in the utilisation of emergency ambulance and ED services suggested numerous factors including ageing were associated with the rise in emergency demand. However it was apparent that emergency demand had not been investigated systematically from an epidemiological perspective.
Therefore the aim of this thesis was to analyse the main elements of the persistent rise in demand across metropolitan Melbourne, with a particular focus on clarifying how the ageing population impacts on emergency demand.
Longitudinal analyses was undertaken, of emergency ambulance transportations,ED presentations and admissions to hospitals through EDs using unique population-based datasets. Numbers and rates of emergency ambulance transportations, ED presentations and emergency admissions from EDs; and ED
and hospital length of stay were analysed. Regression models evaluated the effects of multiple factors on these outcomes.
The volume and rates of utilisation of all emergency health care services over the study periods increased beyond that expected from changes in population growth and ageing.
The study of emergency ambulance transportations provides new evidence about an acceleration in usage by the elderly. All emergency transportations rose by an average annual rate of 4.8%. Predictive modelling suggested further increase up to 69% by 2015.
Investigation of the trends in all ED presentations were analysed and demonstrated a similar increasing disproportionate representation of the elderly over a 10 year period. It was also established that a subgroup of the elderly make multiple visits to EDs; and over 50% of elderly patients are admitted to hospital following ED presentation.
The overall average annual rate of increase in ED presentations by all age groups was 3.6%. ED length of stay increased over the study period for those who were older, more acutely unwell, and required hospital admission. As it was not possible to understand all the factors associated with the rise in ED presentations, a descriptive study explored patient perspectives through
qualitative interviews. Reduced accessibility to general practitioners and an expectation of timely accessible specialist care were the main reasons underpinning their attendance at a metropolitan ED.
Further analysis of patients admitted to hospital from EDs discovered that the growth in emergency hospital admissions was driven by a 60% increase in the number of single day/overnight admissions. This represented an average growth rate of 6.1% per year. This rise in short-stay hospital admissions from EDs may signal that there has been a shift in patterns of care in the ED. It also raises the question of whether ED attendance by this group of patients was necessary.
The significance of this thesis is the identification and measurement of the rise in emergency demand, but with an increasing and accelerating usage of emergency health services by older patients, together with a growing propensity of this subgroup re-present to EDs over time. With population ageing, demand by the elderly will continue to rise and will have a dramatic impact on all elements of emergency healthcare in the future. This information is valuable for policy makers and service providers. It indicates a pressing need to consider how to develop coordinated
systems of care, particularly for the elderly seeking acute care.

急诊患者服务需求的增长是卫生系统面临的重大问题。急诊运输服务、急诊科（EDs）及急性医院（acute hospitals）所承受的日益沉重负担，对资源配置及所提供的护理质量均有影响。各国政府及服务提供者已采取多种策略应对，但急诊医疗需求仍持续增长。人口老龄化亦是卫生服务规划的重要议题。

对国际及国内关于急诊救护车与ED服务使用趋势的文献回顾显示，包括老龄化在内的多种因素与急诊需求增长相关。然而，从流行病学视角（epidemiological perspective）系统研究急诊需求的工作显然尚未开展。

因此，本研究旨在分析墨尔本大都市区急诊需求持续增长的主要因素，尤其聚焦于阐明人口老龄化如何影响急诊需求。

本研究采用独特的人群数据集（population-based datasets），对急诊救护车转运、ED就诊及经ED入院情况开展了纵向分析（Longitudinal analyses）。分析内容包括急诊救护车转运、ED就诊及经ED急诊入院的数量与率；以及ED停留时间与住院时长。回归模型（Regression models）用于评估多种因素对这些结果的影响。

研究期间，所有急诊医疗服务的使用量及使用率增长超出了人口增长与老龄化变化所能解释的预期范围。

对急诊救护车转运的研究为老年人使用量加速增长提供了新证据。所有急诊转运的年均增长率为4.8%。预测模型（Predictive modelling）显示，到2015年这一数字将进一步增长高达69%。

对所有ED就诊趋势的调查分析显示，10年间老年人的占比呈不成比例的类似增长。研究还证实，部分老年人群存在多次ED就诊的情况；且超过50%的老年患者在ED就诊后会入院治疗。

所有年龄组ED就诊的总体年均增长率为3.6%。研究期间，老年患者、病情更急重及需入院治疗者的ED停留时间有所增加。由于无法全面理解ED就诊增长的所有相关因素，本研究通过定性访谈（qualitative interviews）开展描述性研究，探索患者视角。全科医生（general practitioners）可及性降低，以及对及时可及的专科护理（specialist care）的期望，是他们前往都市ED就诊的主要原因。

对经ED入院患者的进一步分析发现，急诊入院增长主要由单日/过夜入院数量增加60%所驱动，这意味着年均增长率为6.1%。经ED入院的短期住院患者数量增长，可能标志着ED护理模式已发生转变，同时也引发了该群体患者是否有必要前往ED就诊的疑问。

本研究的意义在于识别并量化急诊需求的增长，同时揭示老年患者对急诊医疗服务的使用量日益增加且加速上升，以及该亚群随时间推移再次前往ED就诊的倾向不断增强。随着人口老龄化，老年群体的需求将持续增长，并对未来急诊医疗的所有环节产生重大影响。这些信息对政策制定者及服务提供者具有重要价值，表明亟需考虑如何构建协调护理系统（coordinated systems of care），尤其针对寻求急性护理的老年人群。