SheffWHO 2018: Winning Position Paper. OUTBREAKS AND PANDEMICS: ADDRESSING THE NEXT CRISIS

The first of its kind in Sheffield, SheffWHO explored the theme “Outbreaks and Pandemics: Addressing the Next Crisis” from April 27th-29th, 2018. Delegates represented WHO Member States, as well as Non-Governmental Organizations (NGOs), pharmaceutical companies and the media.

Contributing to interdisciplinary and experiential learning in global health, delegates from all disciplines (not just science/health) were encouraged to participate in this event. They discussed, co-operated, and negotiated with other stakeholders to produce resolution papers addressing the simulation theme, as an important global health priority.

The winning position paper, competing with 70 attendees, was by Dr Shukrat O. Salisu-Olatunji. Shukrat completed her Masters in Clinical Research in ScHARR in 2017.

Delegate name: Dr Shukrat O. Salisu-Olatunji 

Region: AFRO (Country: Nigeria) 

Role: Member state delegate 

Twitter handle: @jumisal25 

INTRODUCTION 

Nigeria is known as the most populous nation in Africa with an estimated population of 196 million in April 2018 and a population growth rate of 2.67%[1]. With globalization, international trade and travel across borders, Nigeria is vulnerable to epidemics and outbreaks of infectious diseases from within and without. It is therefore critical to ensure optimal preparedness and response to this global threat and to empower the health system and its stakeholders appropriately with the goal of preventing pandemics and minimising casualties from such occurrences.
Health funding is key in achieving optimal preparedness and response to outbreaks and epidemics, and Nigeria’s health allocation of 4.17% of its annual spending in 2017 is a far cry from the WHO recommendation of 13% [2,3]. The effects of poor health funding are felt across the three tiers of health care and most especially in primary care which is the foundation of health delivery closest to the people. The majority of patients (71.7%) must pay for health care out-of-pocket at the point of service even as the country puts in efforts to achieve Universal Health Coverage. There is high reliance on foreign aid and NGOs as a source of funding for public health initiatives like childhood immunization, HIV treatment, TB treatment among others.

NIGERIAN EXPERIENCE OF OUTBREAKS/EPIDEMICS 

In recent times, Nigeria has experienced outbreaks of public health importance, including the Ebola outbreak in 2014. The strength of local response and collaborations between levels of government greatly influences the outcomes of such outbreaks with respect to acute response and control measures put in place to manage the situation. With the Ebola outbreak which involved several West African countries, the response was highly commendable as Nigeria succeeded in controlling the outbreak within three months and was declared Ebola free by the WHO[4]. The success of the country’s response has been attributed to the Incident management/ Emergency Operation Centre approach which facilitated resource and fund mobilization and coordination of response involving government health facilities, international aid organizations, NGOs and the private sector[5]. This success has however not been replicated with other outbreaks like Lassa fever, cerebrospinal meningitis, cholera and yellow fever which persist in the country. In the country’s experiences, the importance of strengthening health system’s preparedness in terms of personnel, co-ordination of stakeholders and mobilization of resources, provision of needed medications, vaccines and consumables and education of the populace has stood out.

CHALLENGES WITH OUTBREAK PREVENTION AND CONTROL 

The health system’s preparedness and response to outbreaks is dependent on coordination of multiple stakeholders and the public. Poor political commitment especially with regards to funding, weak primary health care system, lack of ownership and community involvement are some of the challenges which negatively impact on outbreak/epidemic response. Political crisis and instability especially in Northern Nigeria also further reduce access to healthcare and jeopardises the chances of effective response to an outbreak. Distrust of the authorities and stigma associated with some communicable diseases like Lassa fever, as well as lack of funds to pay for healthcare services may discourage early reporting and identification of cases, thus increasing the likelihood of spread and epidemic potential of such a condition.

PROPOSED SOLUTIONS

  • Strengthen the foundation of the healthcare system by improving primary health care. Focus on disease prevention, health promotion and notifiable disease surveillance would provide a better defence against outbreaks at all levels of health care. Public health personnel must be aware of minimum standard operating procedures for potential epidemic prone diseases; e.g. case identification, contact tracing and isolation where required. 
  • Create regional laboratories to facilitate rapid diagnosis and enhance surveillance and tracking of outbreaks. 
  • Empower, educate and inform the populace through an effective communication system that enables early identification and reporting of suspected cases at times of outbreaks and minimises anxiety, stigma and harmful practices in the event of an outbreak. 
  • Train healthcare personnel to enhance case management and optimal infection prevention and control in health facilities and the community. 
  • Build capacity of Disease Surveillance and Notification Officers in each state. Strengthen Local governments in training DSNOs to use IDSR guidelines and facilitate timely reporting. 
  • Engage private sector in a focused and coordinated manner. 
  • Key into global initiatives for outbreak control like the recently launched “Eliminate Yellow fever in Africa by 2026”. 

CONCLUSIONS 

Policies and interventions to build capacity of personnel, mobilise funds and needed resources and establish a preparedness and response strategy are essential in addressing the threats of outbreaks/epidemics. Improvements in the health system achieved through foreign aid and support must be sustained to empower the healthcare system at primary, secondary and tertiary levels.

REFERENCES 

  1. Country meters. Live Nigeria population (2018). Current population of Nigeria — Countrymeters [Internet]. 2018 [cited 2018 Apr 17]. Available from: http://countrymeters.info/en/Nigeria/ 
  2. World Health Organization. WHO | Nigeria [Internet]. WHO. World Health Organization; 2018 [cited 2018 Apr 22]. Available from: http://www.who.int/countries/nga/en/ 
  3. Nigeria’s Grossly Inadequate 2017 Health Budget [Internet]. THIS DAY. 2017 [cited 2018 Apr 22]. Available from: https://www.thisdaylive.com/index.php/2017/02/09/nigerias-grosslyinadequate-2017-health-budget/ 
  4. Centers for Disease Control and Prevention. Ebola Virus Disease Outbreak — Nigeria, July– September 2014 [Internet]. Morbidity and Mortality Weekly Report. 2014 [cited 2018 Apr 22]. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6339a5.htm 
  5. Courage KH. How Did Nigeria Quash Its Ebola Outbreak So Quickly? - Scientific American [Internet]. Scientific American. 2014 [cited 2018 Apr 22]. Available from: https://www.scientificamerican.com/article/how-did-nigeria-quash-its-ebola-outbreak-soquickly/

Why A&E? A study into patient factors in low-acuity attendance in an urban district general hospital

Seth White graduated from ScHARR MSc in Clinical Research in 2016. His Masters' dissertation project was supported by Rotherham Emergency Department, and looked into reasons underlying increasing demand on the Emergency Department, particularly for less severe and urgent health problems.

In collaboration with his supervisor Jo Coster, and Jeremy Reynard from Rotherham District General Hospital, Seth's research adresses problems facing Emergency Departments throughout the UK and beyond.

Authors and Affiliations


Seth White MB ChB 1,3; Joanne Coster BSc 1; Jeremy Reynard MBBS FCEM 2

1 School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA
2 Emergency Department, Rotherham District General Hospital, Rotherham, S60 2UD
3 Corresponding author: seth.t.white@gmail.com, MD Anderson Cancer Center, 1515 Holcombe, Houston TX, USA 77030, T: +17137455253

KEYWORDS: Emergency demand, qualitative, interview study, non-urgent attenders, inappropriate attenders, ambulatory attendance, Accident and Emergency, managing demand

Abstract


Introduction: A&E demand is rising inexorably across developed countries. Demographic factors and population health do not fully account for this rapid rise. Considerable demand comes from relatively low-urgency patients, who are likely to be discharged without investigation or treatment. Understanding why such patients choose A&E is important when configuring current and future services.

Methods: Semi-structured interviews undertaken at a local district A&E department situated in an urban deprived area. We included A&E attenders triaged to category 4 or 5 on the Manchester Triage Scale that did not present with an acute traumatic injury or were identified as vulnerable. Transcripts were analysed using framework analysis.

Results: Fifteen patients were recruited and all were interviewed. None described their health problem as an emergency. Patients responded along three main themes. 1) Access to and confidence in primary care; participants lacked confidence in their GP and had difficulty getting appointments. There was a belief that GP consultations were futile as they would inevitably be referred to A&E. 2) Pull factors to A&E; relates to how perceptions of need and positive views of A&E (availability of facilities for investigation, speed and perceived quality) influence health seeking behaviour. 3) Individual and external factors; many patients were referred to A&E and NHS 111 was a common source of referral. Individual factors mostly related to anxiety and pain or using A&E as an informed decision.

Conclusion: These findings demonstrate that patients will select A&E in lieu of other available options due to perceived benefits of A&E care and perceived barriers and limitations to primary care. Previous health care experiences (positive and negative) have a strong influence on future health care choices. The NHS 111 number appears to routinely refer low-urgency patients to A&E and this warrants further investigation.


What this paper adds
What is already known on this subject:
A&E demand is rising rapidly.  Some of this demand is from patients who may not require emergency or urgent care. Why such patients choose A&E is unclear.
What this paper adds:
Patients attend A&E because they believe it is a superior service with better access to investigations, better clinicians and greater ease of access.  These patients are unlikely to choose primary care if given the option.  This has implications for service planning.



Introduction

Rising demand for Accident and Emergency (A&E) care is a well-known and much politicized issue.  Demand has risen 32% over the past ten years alone [1] and is a common problem across developed countries.[2]  The factors driving this increase are not fully understood – population increase and ageing alone do not account for the magnitude of rises seen.  Several interrelated factors have been  suggested to explain this increase; increasingly litigation-averse practices, organizational changes within healthcare systems and increased community expectations are often cited.[3]   

One significant factor, which may be difficult to assess, is a shift in patient behavior.  There is a view that an increasing number of patients bypass primary care and attend A&E ‘inappropriately’.[4]  Many studies have assessed the ‘appropriateness’ of patient attendance in A&E, asking whether patients may have been more appropriately treated elsewhere.  Such studies (using the judgement of physicians) have estimated various inappropriate or avoidable attendance rates of between 6-80%.[5] 

The concept itself is poorly defined in the literature, with individual studies often using independently crafted definitions with little agreement between emergency physicians themselves.[6]  Although the term “inappropriate attender” is difficult to systematically operationalise and may be unhelpful, it is clear that a significant subpopulation present with low-acuity problems to A&E departments.  Such patients may contribute to overcrowding and increase strain on health services.[3]  Attempts to divert such patients to other urgent or immediate healthcare services , such as walk-in centers or other services, have not been shown to reduce A&E demand or influence patients’ health seeking behaviour.[4 7]

This research was therefore undertaken to identify and understand motivating factors in health care decision making for low-acuity patients who choose to attend A&E.  We sought to explore the underlying reasons behind patient decision making and how previous health care experiences and patient views of health services impact and shape future decision making. 

Methods

Setting

The research was undertaken at Rotherham District General A&E department located in England.   This A&E department serves the local area of Rotherham (population: 257,000), which is a relatively ethnically homogenous area [8] with a high index of social deprivation, being ranked in the bottom quintile of local authorities nationally.[9]  The A&E department is currently undergoing refurbishment with plans to integrate a primary care service with the emergency department to form the ‘Emergency Centre’,[10] expected to be completed in 2017.

Participant Selection

Ambulatory adult patients who were triaged to category four or five on the Manchester Triage Scale (the two lowest acuities) were eligible for the study.  Patients with recent onset of trauma (<24 hours), were in vulnerable patient groups or acutely distressed were excluded from the study.  These criteria were designed to capture a less urgent population able to participate in an interview who could feasibly have accessed treatment elsewhere.  Formal prospective assessment of suitability was not made as this was felt to be too subjective to be useful.  Ethical approval was gained from Leicester Central research ethics committee, and study site approval was obtained from NHS Rotherham and HRA prior to the commencement of the study (REC reference: 16/EM/0205).

Exclusion Criteria

-          Pregnancy
-          Acutely distressed
-          Mental health issue
-          Trauma (if <24hrs or injury visible)
-          Formal referral (with letter)
-          Inadequate English
-          Cognitive impairment


Data Collection

All data and information was collected within the A&E department. Patients were screened during triage by the triage nurse, who held a copy of the study eligibility criteria.  Potential participants were then identified to the principle investigator, and were provided with participant information. After having time to read the information, participants were given the opportunity to participate and if they consented, were invited to a quiet side room where consent was taken in writing.  Interviews were semi-structured in nature and recorded on digital Dictaphone.  A topic guide was used to inform the interview and this was further developed and added to as the research progressed.  Initial topics were derived from previous research in the UK and abroad and included a brief chronology of events, perceptions of A&E and primary healthcare services, past experiences and perceived health needs for this care problem.  

A second stage exclusion criteria was applied as recruitment only occurred when the wait between triage and being seen was at least one hour, so as not to delay care to participants.  The study was restricted to regular office hours (9-5 Mon-Fri) to avoid factors around out-of-hours access, as the study was primary concerned with patients who could feasibly have chosen to attend a primary care service.  Interviews were carried out during summer 2016.

Analysis

Interviews were transcribed verbatim by the lead researcher (SW). Transcripts were analyzed within NVIVO 11 software [11] using the method of framework analysis, which involves a series of clearly defined, systematic and sequential steps.[12]  Following familiarization with the interview transcripts, initial themes were coded around basic concepts from interview responses such as “anxiety” or “perceived clinician quality” to develop a working analytic framework.  These were then discussed and revised with a second researcher (JC) and applied to subsequent interview transcripts.  Revisions were undertaken over several meetings.  Continuing the same process, interview data was gradually interpreted and collated into three superordinate themes: “access to and confidence in primary care”, “pull factors to A&E”, and a third, looser superordinate theme “individual and external factors”. 

Results

Participant characteristics

Fifteen participants were recruited; participants ranged in age from 18 to 63 and included seven women and eight men with a broad variety of presenting complaints (see Table 1). Six participants gave home addresses outside of the catchment area of Rotherham A&E. Disposal outcome was only available for thirteen participants – one participant’s outcomes could not be traced and another was recorded only as ‘seen by GP’. Four participants brought a relative into the interview (no carers were interviewed) but only three contributed to the interviews.

Out of the thirteen participants with disposal outcomes available, five received advice only, and three received advice and a prescription. Only one participant received a specialty referral and no participants were admitted. One participant did not wait to be seen by a clinician after the interview. Two received wound care in the department, both judged to be candidates for wound care in general practice by the researcher. Participants came from a geographically diverse area and nearly all participants resided in areas with high levels of deprivation. Six participants had home addresses listed with an A&E in closer geographical proximity (although location of incident/onset of illness was not recorded). Three participants reported travelling to Rotherham in preference of another A&E during the interview (with one being advised to go to specifically Rotherham via 111 due to presence of maxillofacial surgeons – though they were not seen by the maxillofacial surgeons).

Table 1 - participant characteristics




ID#
Age
Sex
Complaint
Outcome
Deprivation quintile
Closest ED
1
63
M
Growth on nose
Seen by GP
5th
Rotherham
2
57
M
R leg problem
Advice
5th
Mexborough (MIC)
3
41
M
L side numbness
Advice, prescription
4th
Rotherham
4
18
M
Injury to R foot
Dressing, local anaesthetic, advice
3rd
Rotherham
5
54
M
Pain L knee
Prescription, advice
4th
Rotherham
6
27
F
Dental problem
Prescription, advice
5th
Barnsley
7
41
F
Knee prob
Outcome unavailable


8
52
F
Left leg pain
Did not wait

Sheffield
9
32
M
R foot injury
Advice
5th
Rotherham
10
32
M
R leg injury
Advice
5th
Rotherham
11
21
F
Left knee injury
Observation, specialty referral, advice
3rd
Mexborough (MIC)
12
30
F
Groin pain
Observation, advice
3rd
Doncaster
13
26
F
R foot wound prob
Wound cleaning, advice
3rd
Bassetlaw
14
51
M
RTC/neck pain
Advice
2nd
Rotherham
15
55
F
R wrist injury
Advice
5th
Rotherham
 

MIC = minor injury centre. Closest ED – closest emergency department or nurse led minor injuries unit (walk-in centres not included).  DQ = deprivation quintile

Thematic analysis

After applying several revisions to the coding structure, a definitive thematic framework emerged describing the factors behind A&E attendance.  Twenty-one individual subthemes were identified during the initial coding and many of these were closely related or interlinked. All respondents contributed to at least one main theme and often more. Three overarching themes were identified and each contained subthemes: access to and confidence in primary care, pull factors to A&E, and individual and external factors.

Bypassing Primary Care

Access to and confidence in primary care related very closely to pull factors to A&E. A&E was almost universally better regarded than primary care, even in participants who voiced positive opinions of their general practitioner.  Many participants dismissed the idea of attending primary care as ‘futile’ and were attracted to A&E as able to provide more definitive care.  Many participants also believed that if they attended their GP it was merely delaying the inevitable A&E attendance and referred to ‘cutting out the middle man’ when describing their reasoning behind this.
“Just because it was something that I didn’t know what it was, I thought I’d cut the middle man out and go straight to A&E” Participant 2
“I just thought that I'd just cut the middle man out by coming here for X-ray because I thought I would need one”Participant 5
"Whenever I've gone to the walk in or phoned 111 they tell me A&E straight away, or that you need to be seen within the next 4 hours…….so now when I get the pains I jump in a taxi and I come here.”Participant 3
“It’s just that every time we’ve been to see the GP it’s that they’ve more or less told him that they don’t specialize in that kind of thing so we go to A&E and you’ll get better treatment.”Participant 1
This closely related to three subthemes: 1) Perceived need for diagnostic equipment, 2) Difficulty in accessing timely primary care, and 3) Lack of confidence in primary care.
Perceived need for diagnostic services was an important factor in many decisions and a very prominent theme throughout the interviews.  Radiographs were commonly thought to be required.  No other specific investigations were listed. 
“So I was going to ring the doctor and then I thought they might have to do an x-ray so I thought I’d come here and get it checked out as soon as possible” Participant 9
“I just thought that by coming here I'd get an X-ray” Participant 5
Difficulty in accessing the general practitioner was also very common theme in the research – some participants spoke of long waits, and first-come-first-serve telephone appointments as barriers to GP attendance.  It is worth noting that this was still a prominent theme despite all the research being conducted during normal weekday working hours.
“The thing is that it’s really hard to get an appointment with them they’ve got a system where you need to ring at bang on eight in the morning and it’s either one or half one in the afternoon to get an afternoon appointment. But if you try to ring at eight… I’ve had it before where I’ve tried to get an appointment and it’s three [minutes] past eight and they’ve all gone” Participant 11

Confidence in general practice was mixed overall, with several participants speaking of previous issues or disagreements that led them to seek alternate care in A&E.
“I’ll tell you when I got there I couldn’t breathe, I’ve got COPD, and the thing he said to me that the best thing to do was to go up to the moors, park car, and take a few deep breaths. And that night, ended up in hospital with a blood clot on the lung and pneumonia. That’s how good he [GP] were.”Participant 1

Although opinions of GP ability were mixed, there was generally a greater confidence in emergency physicians.
“I do like hospital because of all the equipment they have, everything right here. But when you come here it's like they know what they're doing more than other places” – Participant 4

Choice and External Influences on Agency

Individual and external factors is a looser association of themes. This represents factors in the more immediate decision making process. Anxiety and perceived severity of illness was cited by several participants, and was an expected finding based on previous research.  It was however, less prominent than expected.  Some patients expressed uncertainty. 
“I’m a little bit worried – do I need seeing to straight away?” Participant 2

“Well I’m not quite sure… I don’t know 100% whether or not I should be in A&E. I don’t know if I qualify to be in A&E with my injury. Well I don’t know it’s not really an emergency. It is an accident though! But not an emergency. So I don’t know whether it was right to come to A&E” Participant 13
A number had been referred to go to A&E by 111 and a similar number by friends, colleagues or informally by other medical professionals. Interestingly a small but significant minority made an informed choice based on convenience related factors, resulting in travelling not insignificant distances past other A&E departments to reach their preferred A&E department.
“Well yeah, I do actually live in Sheffield. I don't like the northern general it's always too busy… and it's a nightmare parking at the northern general isn't it?” Participant 7
One participant stated that Rotherham A&E was their usual place of medical care. Participants were aware of pressure on A&E departments and often had relatively detailed knowledge of locally available services.

Discussion

Implications for service delivery

This research builds on previous research into patient decision-making in seeking A&E care and explores why patients in a deprived population setting attend A&E in lieu of other health care services for low urgency problems in-hours.  Patients were unanimous in their perception that A&E is the best place to attend for ease of access and availability of diagnostic equipment.  Patients perceived A&E as a more ‘definitive’ option for care, implying that general practice was unable to decisively attend to their complaints.  This relates to the concept of convenience, which has strongly occurred throughout the literature.[3 13]  What was distinct in this research was the concept of futility associated with GP attendance; many patients believed that they would have ultimately been referred to hospital to either A&E or for investigations available in A&E.  

Anxiety and perceived severity were less frequent complaints than expected; participants did not believe their problems were emergencies.  External sources of advice appear to have played a part; some patients cited discussions with healthcare professionals informally, or the 111 service.
It is clear from the responses within the study that A&E attendance in low-urgency patients is largely a logical and considered choice, as it meets their perceived health needs with convenience.  Although reasons for attending A&E varied between participants, it was evident that most respondents had considered their options before attending.  

In this sense A&E may be perceived to be ‘a victim of its own success’.[14]  Confidence and positive perceptions of the service may be increasing footfall through the service and inadvertently decreasing use of other, more conventional means of non-urgent healthcare for reasons that go beyond simple indecision/anxiety and access issues.  Public satisfaction with General Practice, although high, has been on a downward trend for several years.[15]  It is possible that changing perceptions between services are playing a role in demand. 

Given that, from a patient perspective, A&E is a logical and convenient choice, the very concept of “appropriateness” around attendance is unhelpful  as it suggests patients are expected to make a decision on their care which physicians themselves sometimes find difficult to explain, as discussed previously.[6]  Furthermore, the very logic of approaching the problem as one of “appropriateness” is fundamentally flawed.  It is unreasonable to place the burden of decision of choice on patients with no medical expertise and can lead to inequity within the healthcare system.  Such opinions have been raised before,[14] emphasizing the need for a patient-centered approach to health service design.

This research also helps explain why the extension of primary care options has not demonstrably impacted demand.[7]  Availability of primary care may have some influence, but a majority appear to be deliberately seeking A&E care for the clear benefits it brings.  

The role of 111 in referring patients unnecessarily may need to be investigated further as 111 was a common source of referral of low urgency patients to A&E.  As 111 was introduced to provide advice to self-care and encourage alternatives to A&E, this is a counterproductive outcome.  This is consistent with available evidence which does not demonstrate any reduction in A&E demand with 111 rollout.[16]  

As many A&E departments integrate primary care services into emergency departments this research demonstrates the logic of this, from a patient perspective.  A unified triage service between primary and emergency services may be necessary as patients may, for various reasons, select emergency care in preference if offered a choice.  Future research into the integration of primary care and emergency care services and research exploring the organizational responsibilities and remit of each service within a shared system is required.

Limitations

Though the study appears to have captured a largely low-urgency group of patients, it is not certain how generalizable these answers may be to the broader population.  Certain populations, specifically vulnerable groups such as pregnant women and children, were excluded on ethical grounds and may have important differences in their presentation factors which were not assessed here.  Children may be an especially important source of low-urgency demand, as has been suggested by others.[17]  Furthermore, this is a single-centre study and the population captured here may not be generalizable to the wider population, given the particular demographic features of this setting.

Finally, the findings must be interpreted in the context where they were taken.  The principle investigator is a physician who has previously worked in the department.  Participants were made aware of this fact and may have spoken of A&E in a more positive light than they would have otherwise.  The authority of the investigator may also have placed additional pressure on participants to give socially desirable answers.

Conclusion

Low urgency patients often choose A&E due to perceived benefits in clinician quality, access and available diagnostic equipment as well as other external influences and patient factors.  Such patients may actively be choosing to come to A&E for its perceived benefits and may not be dissuaded by the offer of parallel services.  This research supports the logic of shared triage in the context of a joint primary care-emergency service.  The research also implies difficulty in applying the Keogh report, as low urgency patients may be less likely to seek care outside of an A&E setting. 

Disclaimer

This study has received no funding and was undertaken in the context of a master’s dissertation by Seth White supervised by Jo Coster at the University of Sheffield.  There are no conflicts of interest.


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