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The changing role of the emergency department : an analysis of emergency department utilization at Lions… Lakes, Ronald William 1977

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THE CHANGING ROLE OF THE EMERGENCY DEPARTMENT: AN ANALYSIS OF EMERGENCY DEPARTMENT UTILIZATION AT LIONS GATE HOSPITAL by RONALD WILLIAM LAKES B.Comm., U n i v e r s i t y B.A., U n i v e r s i t y M.A., U n i v e r s i t y o f S a s k a t c h e w a n , 1968 of S a s k a t c h e w a n , 1971 o f T o r o n t o , 1972 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF" BUSINESS ADMINISTRATION i n THE FACULTY OF COMMERCE AND BUSINESS ADMINISTRATION We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1977 C o p y r i g h t R o n a l d W i l l i a m L a k e s , 1977 In presenting th i s thes is in pa r t i a l fu l f i lment of the requirements for an advanced degree at the Univers i ty of B r i t i s h Columbia, I agree that the L ibrary sha l l make it f ree ly ava i l ab le for reference and study. I further agree that permission for extensive copying of th is thesis for scho lar ly purposes may be granted by the Head of my Department or by his representat ives. It is understood that copying or pub l i ca t ion of th is thes is fo r f inanc ia l gain sha l l not be allowed without my writ ten permission. Department of Commerce and B u s i n e s s A d m i n i s t r a t i o n The Univers i ty of B r i t i s h Columbia 2075 W e s b r o o k P l a c e V a n c o u v e r , C a n a d a V 6 T 1W5 Date A p r i l , 1977 ABSTRACT The emergency d e p a r t m e n t o f L i o n s Gate H o s p i t a l was s t u d i e d b o t h i n r e g a r d t o t h e p a t i e n t s ' c u r r e n t v i s i t t o t h i s f a c i l i t y and i n r e g a r d t o t h e p a t i e n t s ' o t h e r s o u r c e s o f a m b u l a t o r y m e d i c a l c a r e . The o b j e c t i v e s o f t h e s t u d y were: (1) t o u n d e r s t a n d why p a t i e n t s seek c a r e a t L i o n s G a t e ' s emergency d e p a r t m e n t ; (2) t o d i s c o v e r how t h i s f a c i l i t y f i t s i n t o t h e p a t i e n t s ' o v e r a l l p a t t e r n s o f m e d i c a l c a r e ; and (3) on t h e b a s i s o f t h e above d a t a , t o p r o p o s e any a p p r o p r i a t e c hanges i n t h e o r g a n i z a t i o n o f t h e emergency d e p a r t m e n t . The s t u d y was c o n d u c t e d d u r i n g 14 d a y s i n September, 1974; t h e s a m p l i n g frame c o v e r e d a l l h o u r s o f t h e day and a l l days o f t h e week. D a t a were g a t h e r e d by q u e s t i o n n a i r e s a d m i n i s t e r e d i n t h e emergency d e p a r t m e n t , w i t h 85.60 p e r c e n t o f t h e sample r e s p o n d i n g . The i n c r e a s e i n demand f o r emergency d e p a r t m e n t s e r v i c e s has been a t t r i b u t e d t o a v a r i e t y o f f a c t o r s . The p r e s e n t s t u d y d e t e r m i n e d t h a t p r i v a t e p h y s i c i a n s and t h e i r n o n - a v a i l a b i l i t y a r e t h e p r e d o m i n a n t f a c t o r s c o n t r i b u t i n g t o emergency d e p a r t m e n t usage a t L i o n s Gate H o s p i t a l , i n d i c a t i n g t h a t t h i s f a c i l i t y i s s u b s t i t u t i n g f o r t h e w i d e r p r i m a r y c a r e s y s t e m . D a t a p e r t a i n -i n g t o t h e p a t i e n t s ' o v e r a l l p a t t e r n s o f m e d i c a l c a r e p r o v i d e d f u r t h e r e v i d e n c e t h a t t h e emergency d e p a r t m e n t has g a i n e d wide a c c e p t a n c e by t h e p a t i e n t s as a s o u r c e o f p r i m a r y m e d i c a l c a r e . i i i M o r e o v e r , t h e emergency d e p a r t m e n t was i d e n t i f i e d as an i m p o r -t a n t and c o n t i n u i n g s o u r c e o f c a r e i n t h e m e d i c a l c a r e p a t t e r n s o f many o f i t s p a t i e n t s . As a r e s u l t o f t h e above f i n d i n g s , i t was recommended t h a t f u t u r e p l a n s f o r e i t h e r t h e m o d i f i c a t i o n o r e x p a n s i o n o f L i o n s G a t e ' s emergency d e p a r t m e n t s h o u l d i n c l u d e t h e e s t a b l i s h -ment w i t h i n t h e d e p a r t m e n t o f a w a l k - i n a m b u l a t o r y c l i n i c . The p r o p o s e d a m b u l a t o r y c a r e d e p a r t m e n t , c o n s i s t i n g o f an emergency c e n t r e and p r i m a r y c a r e c l i n i c , would a s s i s t L i o n s Gate H o s p i t a l t o f i t i t s s e r v i c e s t o t h e m e d i c a l c a r e needs w h i c h i t s p a t i e n t s e x h i b i t . i v TABLE OF CONTENTS ABSTRACT . . . . i i LIST OF TABLES v i ACKNOWLEDGEMENTS v i i i CHAPTER I INTRODUCTION • 1 S i g n i f i c a n c e o f t h e P r o b l e m 1 R e s e a r c h O b j e c t i v e s 3 I I LITERATURE REVIEW 6 The Demand f o r Emergency Department S e r v i c e s . . . . 6 F a c t o r s C o n t r i b u t i n g t o t h e Demand f o r Emergency D e p a r t m e n t S e r v i c e s 13 P a t i e n t s ' O v e r a l l M e d i c a l C a r e P a t t e r n s . . 21 I I I RESEARCH DESIGN 29 Sample 29 Da t a C o l l e c t i o n 30 L i m i t a t i o n s o f t h e St u d y - 3 1 IV DATA ANALYSIS ' . . 3 4 P a t i e n t s ' C u r r e n t V i s i t t o t h e Emergency D e p a r t m e n t 35 P a t i e n t s ' O v e r a l l P a t t e r n s o f M e d i c a l C a r e 49 V CONCLUSION 61 Summary o f F i n d i n g s 61 I m p l i c a t i o n s 64 BIBLIOGRAPHY 70 APPENDIX 1 P e r c e n t a g e I n c r e a s e i n Emergency Department V i s i t s t o H o s p i t a l s i n th e U n i t e d S t a t e s 83 APPENDIX 2 P e r c e n t a g e o f Emergency D e p a r t m e n t V i s i t s J u d g e d t o be N o n u r g e n t a t H o s p i t a l s i n t h e U n i t e d S t a t e s . . . 8 4 V APPENDIX 3 Emergency D e p a r t m e n t S t u d i e s C o n d u c t e d i n F o r e i g n C o u n t r i e s . . . 86 APPENDIX 4 Q u e s t i o n n a i r e 87 APPENDIX 5 T e m p o r a l V a r i a t i o n s i n P a t i e n t s ' M e d i c a l C o m p l a i n t s 94 APPENDIX 6 S o c i o e c o n o m i c C h a r a c t e r i s t i c s o f t h e Emergency Department P a t i e n t s . . . 100 V I L I S T OF TABLES TABLE PAGE 1 P e r c e n t a g e I n c r e a s e i n Emergency D e p a r t m e n t V i s i t s t o H o s p i t a l s i n Canada And The U n i t e d S t a t e s 7 2 P e r c e n t a g e o f Emergency D e p a r t m e n t V i s i t s J u d g ed t o be Non-Urgent a t C a n a d i a n H o s p i t a l s 10 3 P e r c e n t a g e D i s t r i b u t i o n o f M i c h i g a n P a t i e n t s by A t t e m p t to C a l l P h y s i c i a n B e f o r e Emergency D e p a r t m e n t V i s i t 15 4 P a t i e n t s ' S o u r c e o f R e f e r r a l t o The Emergency D e p a r t m e n t 20 5 D i s t r i b u t i o n o f P a t i e n t s by P a t i e n t s ' A s s e s s -ment o f The U r g e n c y o f T h e i r P r e s e n t i n g Com-p l a i n t 36 6 D i s t r i b u t i o n o f P a t i e n t s by N a t u r e o f P r e s e n t -i n g C o m p l a i n t 37 7 P e r c e n t a g e D i s t r i b u t i o n o f P a t i e n t s by N a t u r e and D u r a t i o n of P r e s e n t i n g C o m p l a i n t 38 8 P e r c e n t a g e D i s t r i b u t i o n o f P a t i e n t s W i t h i n E a c h N a t u r e o f C o m p l a i n t C a t e g o r y by D u r a t i o n of C o m p l a i n t 38 9 P e r c e n t a g e D i s t r i b u t i o n o f P a t i e n t s W i t h i n E a c h D u r a t i o n o f C o m p l a i n t C a t e g o r y by P a t i e n t s ' A s s e s s m e n t o f U r g e n c y 39 10 D i s t r i b u t i o n o f P a t i e n t s by S o u r c e o f R e f e r r a l t o The Emergency D e p a r t m e n t 40 11 D i s t r i b u t i o n of P a t i e n t s by Reasons F o r Seek-i n g T r e a t m e n t a t L i o n s G a t e ' s Emergency D e p a r t m e n t 41 v i i TABLE PAGE 12 D i s t r i b u t i o n o f P a t i e n t s by A t t e m p t t o C o n t a c t a P h y s i c i a n B e f o r e Emergency D e p a r t -ment V i s i t 4 3 13 P e r c e n t a g e D i s t r i b u t i o n o f P a t i e n t s W i t h i n E a c h N a t u r e And D u r a t i o n o f C o m p l a i n t C a t e -g o r y by A t t e m p t to C o n t a c t a P h y s i c i a n B e f o r e Emergency Department V i s i t 44 14 P e r c e n t a g e D i s t r i b u t i o n o f P a t i e n t s W i t h i n E a c h S e v e r i t y o f C o m p l a i n t C a t e g o r y by A t t e m p t t o C o n t a c t a P h y s i c i a n B e f o r e Emer-gency D e p a r t m e n t V i s i t 45 15 D i s t r i b u t i o n o f P a t i e n t s by P a t i e n t s ' R easons F o r C u r r e n t Emergency De p a r t m e n t V i s i t 47 16 D i s t r i b u t i o n o f P a t i e n t s by P a t i e n t s ' R e l a -t i o n s h i p W i t h a F a m i l y D o c t o r 51 17 D i s t r i b u t i o n o f P a t i e n t s by P a t i e n t s ' Reasons F o r Not H a v i n g a F a m i l y D o c t o r 51 18 D i s t r i b u t i o n o f P a t i e n t s A c c o r d i n g t o S o u r c e s o f A m b u l a t o r y C a r e Used D u r i n g The P a s t Year 52 19 D i s t r i b u t i o n o f P a t i e n t s by Number o f Emer-gency D e p a r t m e n t V i s i t s D u r i n g The P a s t Y e a r And by H o s p i t a l S i t e 53 20 D i s t r i b u t i o n o f P a t i e n t s by Volume S o u r c e of C a r e 55 21 D i s t r i b u t i o n o f P a t i e n t s by C e n t r a l S o u r c e o f C a r e 56 22 F r e q u e n c y D i s t r i b u t i o n o f P a t i e n t s by C e n t r a l And Volume S o u r c e s o f C a r e 57 23 P e r c e n t a g e D i s t r i b u t i o n o f P a t i e n t s by C e n t r a l And Volume S o u r c e s o f C a r e 58 24 P e r c e n t a g e D i s t r i b u t i o n o f P a t i e n t s W i t h i n E a c h C e n t r a l S o u r c e o f C a r e C a t e g o r y by Volume S o u r c e o f C a r e 59 v i i i ACKNOWLEDGEMENTS I am i n d e b t e d t o many p e o p l e who c o n t r i b u t e d t o t h e com-p l e t i o n o f t h i s t h e s i s . A s p e c i a l acknowledgement, however, i s due t o my w i f e , G e r r y , whose many s a c r i f i c e s made i t p o s s i b l e f o r me t o a t t e n d g r a d u a t e s c h o o l a t b o t h t h e U n i v e r s i t y o f T o r o n t o and t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a . The f a c t t h a t she made t h e s e s a c r i f i c e s w i t h o u t c o m p l a i n t a l l o w e d me to e n j o y my s t u d i e s a t b o t h u n i v e r s i t i e s . I am a l s o i n d e b t e d t o G e r r y f o r t h e many h o u r s i t t o o k t o t y p e t h i s t h e s i s . To you, G e r r y , a s p e c i a l t h a n k you. I would a l s o l i k e t o t h a n k Dr. I l a n V e r t i n s k y , my t h e s i s c o m mittee c h a i r m a n , f o r h i s g u i d a n c e and s u p p o r t t h r o u g h o u t t h e c o u r s e o f t h i s s t u d y . In a d d i t i o n , t h a n k s a r e due t o t h e o t h e r members o f my t h e s i s c o m m i t t e e , Dr. Vance M i t c h e l l and Dr. R i c h a r d B a r t h , f o r t h e i r a s s i s t a n c e and c o n s t r u c t i v e c r i t i c i s m s . The h e l p o f J a n C o n s t a n t i n e s c u i n t h e w r i t i n g o f t h e computer program i s g r a t e f u l l y a c k n o w l e d g e d , as i s t h e h e l p o f Mr. L l o y d D e t w i l l e r d u r i n g t h e i n i t i a l s t a g e s o f t h e p r o j e c t . Thanks a r e a l s o due t o t h e a d m i n i s t r a t o r s and m e d i c a l s t a f f o f L i o n s Gate H o s p i t a l f o r a l l o w i n g me a c c e s s t o t h e emergency d e p a r t m e n t . In p a r t i c u l a r , I am i n d e b t e d t o Mrs. M. Gagnon and t h e a d m i t t i n g c l e r k s f o r t h e i r v a l u a b l e h e l p d u r i n g t h e c o l l e c t i o n o f t h e d a t a . F i n a l l y , I would l i k e t o t h a n k t h e many anonymous p a t i e n t s who, by c o m p l e t i n g my q u e s t i o n n a i r e under t r y i n g c i r c u m s t a n c e s , made t h i s s t u d y p o s s i b l e . 1 CHAPTER I INTRODUCTION S i g n i f i c a n c e o f t h e P r o b l e m The i n c r e a s i n g demand f o r emergency d e p a r t m e n t s e r v i c e s has been w e l l documented i n t h e l i t e r a t u r e . In a d d i t i o n , many r e s e a r c h e r s r e p o r t t h a t much o f t h e demand f o r emergency d e p a r t -ment s e r v i c e s i s f o r t h e t r e a t m e n t o f n o n u r g e n t m e d i c a l p r o b l e m s ( i . e . , t h e d i s o r d e r i s n o n a c u t e or minor i n s e v e r i t y and does not r e q u i r e t h e r e s o u r c e s o f an emergency d e p a r t m e n t ) . In e s s e n c e , th e r o l e o f t h e emergency d e p a r t m e n t i n t h e h e a l t h c a r e s y s t e m has been r a d i c a l l y a l t e r e d d u r i n g t h e l a s t t h r e e d e c a d e s . What was o r i g i n a l l y t h e " a c c i d e n t room," d e s i g n e d t o p r o v i d e a c u t e c a r e f o r t h e s e r i o u s l y i l l and i n j u r e d , i s now p e r c e i v e d by a l a r g e p r o p o r t i o n o f t h e p o p u l a t i o n as t h e a p p r o p r i a t e s o u r c e o f p r i m a r y m e d i c a l c a r e f o r a wide a s s o r t m e n t o f m e d i c a l , p e d i a t r i c , s u r g i c a l and even p s y c h i a t r i c p r o b l e m s ( H a m i l t o n , 1974; Skud d e r , M c C a r r o l l & Wade, 1961). U n l e s s t h e w i d e r h e a l t h c a r e d e l i v e r y s y s t e m i s a l t e r e d , t h e number o f p a t i e n t v i s i t s t o emergency d e p a r t m e n t s w i l l s u r e l y c o n t i n u e t o r i s e . F u r t h e r m o r e , i t i s l i k e l y t h a t i n c r e a s i n g numbers o f p a t i e n t s w i l l seek t r e a t m e n t f o r n o n u r g e n t p r o b l e m s a t emergency d e p a r t m e n t s . O b v i o u s l y , however, t h e s e p r e d i c t i o n s 2 a p p l y o n l y t o g e n e r a l t r e n d s , and a r e by no means r e l i a b l e i n d i -c a t o r s o f t h e f u t u r e u t i l i z a t i o n o f any i n d i v i d u a l h o s p i t a l . E a c h h o s p i t a l w i l l e x p e r i e n c e i t s own p e c u l i a r u t i l i z a t i o n p a t t e r n s and p r o b l e m s . These d i f f e r e n c e s may be due t o t h e s o c i o -economic c h a r a c t e r i s t i c s o f t h e p e o p l e who r e s i d e i n t h e s e r v i c e a r e a o f t h e h o s p i t a l , t h e e x t e n t o f u r b a n i z a t i o n and i n d u s t r i a l i -z a t i o n o f t h e a r e a , l o c a l p a t t e r n s o f h e a l t h c a r e d e l i v e r y , h o s p i t a l p o l i c y , and so f o r t h . Some emergency d e p a r t m e n t s may be f u l f i l l i n g t h e r o l e o f a 24-hour g e n e r a l p r a c t i t i o n e r , w h i l e o t h e r s may be t r e a t i n g a r e l a t i v e l y s m a l l p r o p o r t i o n o f n o n u r g e n t m e d i c a l d i s o r d e r s (Vaughan & Gamester, 1966'ia) . P u b l i s h e d r e p o r t s f r e q u e n t l y r e f e r t o t h e "emergency d e p a r t -ment c r i s i s . " U n f o r t u n a t e l y , t h e l i t e r a t u r e c o n t a i n s c o n f l i c t i n g v i e w s on how t o s o l v e t h e p r o b l e m s g e n e r a t e d by t h e c h a n g i n g demand f o r emergency s e r v i c e s . Most o f t h e s o l u t i o n s w h i c h a r e p r o p o s e d a r e t o o g e n e r a l t o be o f v a l u e t o t h e h o s p i t a l a d m i n i s -t r a t o r . In r e a l i t y , t h e s o l u t i o n t o any p a r t i c u l a r h o s p i t a l ' s emergency d e p a r t m e n t p r o b l e m s must be d e r i v e d from f a c t u a l know-l e d g e c o n c e r n i n g t h e h o s p i t a l ' s u n i q u e p a t t e r n s o f u t i l i z a t i o n ( I o t t , Webb, Thompson & P e a r s o n , 1974; Vaughan & Gamester, 1966 b ) . Those r e s p o n s i b l e f o r p l a n n i n g t h e f u t u r e o f t h e emer-gency d e p a r t m e n t s h o u l d know why p a t i e n t s ' seek t r e a t m e n t a t t h i s f a c i l i t y , and how t h i s f a c i l i t y r e l a t e s t o t h e p a t i e n t s ' o t h e r s o u r c e s o f m e d i c a l c a r e . Once t h i s i n f o r m a t i o n i s o b t a i n e d , p l a n s can be d e v i s e d t o improve emergency d e p a r t m e n t s t a f f i n g and o r g a n i z a t i o n ; i f d e s i r e d , p l a n s f o r a l t e r n a t i v e f a c i l i t i e s c a n be 3 p r o p o s e d so t h a t t h e f u n c t i o n s o f the emergency d e p a r t m e n t can be a l t e r e d . R e s e a r c h O b j e c t i v e s The o b j e c t i v e s o f t h e p r e s e n t s t u d y were t h r e e f o l d : F i r s t , t o u n d e r s t a n d why p a t i e n t s seek c a r e a t t h e emergency d e p a r t m e n t of L i o n s Gate H o s p i t a l ; s e c o n d , t o l e a r n how t h i s f a c i l i t y f i t s i n t o t h e p a t i e n t s ' o v e r a l l p a t t e r n s o f m e d i c a l c a r e ; and, t h i r d , on t h e b a s i s o f t h e above d a t a , t o p r o p o s e any a p p r o p r i a t e changes i n t h e o r g a n i z a t i o n o f t h e emergency d e p a r t m e n t . The f i r s t o b j e c t i v e was t o u n d e r s t a n d why p a t i e n t s s eek c a r e a t t h e emergency d e p a r t m e n t o f L i o n s Gate H o s p i t a l . T h i s phase o f t h e p r o j e c t f o c u s e d on t h e p a t i e n t s ' c u r r e n t v i s i t t o t h e h o s p i t a l . I n f o r m a t i o n was o b t a i n e d w i t h r e s p e c t t o t h e p a t i e n t s ' a s s e s s m e n t o f t h e u r g e n c y o f t h e i r m e d i c a l p r o b l e m s , t h e s p e c i f i c mode o f r e f e r r a l t o t h e emergency d e p a r t m e n t , t h e r e a s o n s why L i o n s Gate H o s p i t a l was c h o s e n by t h e p a t i e n t s ' , and t h e l i k e . P a r t i c u l a r a t t e n t i o n was f o c u s e d on t h e e x t e n t t o w h i c h p r i v a t e p h y s i c i a n s c o n t r i b u t e t o emergency d e p a r t m e n t u s a g e , i n c l u d i n g t h e amount o f p h y s i c i a n r e f e r r a l , a c t u a l p h y s i c i a n n o n - a v a i l a b i l i t y , and p e r -c e i v e d p h y s i c i a n n o n - a v a i l a b i l i t y . D a t a was c o l l e c t e d t o d e t e r -mine whether the p a t i e n t s a t t e m p t e d t o c o n t a c t a p h y s i c i a n b e f o r e coming t o t h e ^ h o s p i t a l , and whether the p a t i e n t s were s u c c e s s f u l i n t h i s a t t e m p t . P a t i e n t s who d i d n o t a t t e m p t t o c o n t a c t a p h y s i c i a n were q u e s t i o n e d as t o why t h e y d i d n o t seek t r e a t m e n t o r a d v i c e f r o m a p h y s i c i a n b e f o r e t h e i r emergency d e p a r t m e n t v i s i t . 4 In o r d e r t o u n d e r s t a n d t h e r o l e o f t h e emergency d e p a r t -ment i n t h e h e a l t h c a r e s y s t e m , one must examine how t h i s f a c i -l i t y r e l a t e s t o t h e p a t i e n t s ' o t h e r s o u r c e s o f m e d i c a l c a r e . C o n s e q u e n t l y , as w e l l as s t u d y i n g t h e p a t i e n t s ' b e h a v i o u r w i t h r e g a r d t o t h e i r c u r r e n t v i s i t t o t h e emergency d e p a r t m e n t , t h e p r o j e c t i n v e s t i g a t e d t h e p a t i e n t s ' o t h e r a m b u l a t o r y m e d i c a l c a r e s o u r c e s . F o r example, we d e t e r m i n e d whether t h e p a t i e n t s have a f a m i l y d o c t o r , and t h u s i d e n t i f i e d t h e s u b s e t o f p a t i e n t s who may be r e l y i n g on t h e emergency d e p a r t m e n t t o s e r v e as t h e i r " f a m i l y d o c t o r . " F u r t h e r m o r e , t h e p a t i e n t s were i n s t r u c t e d t o i n d i c a t e t h e number o f t i m e s t h e y have r e c e i v e d m e d i c a l t r e a t -ment d u r i n g t h e p r e v i o u s y e a r ( i n c l u d i n g t h e i r c u r r e n t v i s i t t o t h e emergency d e p a r t m e n t ) , and t h e m e d i c a l s o u r c e s from w h i c h t h e t r e a t m e n t was o b t a i n e d . From t h i s i n f o r m a t i o n , t h e p a t i e n t s ' volume s o u r c e o f c a r e was d e t e r m i n e d ; i . e . , t h e f a c i l i t y w h i c h t h e y most o f t e n u t i l i z e d d u r i n g t h e p r e v i o u s 12 months. In a d d i t i o n , t h e p a t i e n t s were a s k e d t o s p e c i f y t h e i r c e n t r a l s o u r c e o f c a r e ; i . e . , t h e f a c i l i t y w h i c h t h e y have t h e g r e a t e s t f a i t h o r t r u s t i n f o r t h e i r m e d i c a l t r e a t m e n t and a d v i c e . The c o n c e p t o f c e n t r a l s o u r c e o f c a r e i s i m p o r t a n t i n a s s e s s i n g t h e q u a l i t a t i v e i m p o r t a n c e o f t h e v a r i o u s s o u r c e s o f m e d i c a l c a r e . Thus, th e r o l e o f t h e emergency d e p a r t m e n t i n t h e p a t i e n t s ' o v e r a l l p a t t e r n s o f m e d i c a l c a r e was d e t e r m i n e d by u s i n g b o t h o b j e c t i v e and s u b j e c t i v e c r i t e r i a . 5 F i n a l l y , t h e t h i r d o b j e c t i v e o f t h e p r o j e c t was t o c o n -s i d e r a p p r o p r i a t e o r g a n i z a t i o n a l changes f o r L i o n s G a t e ' s emergency d e p a r t m e n t . I t i s l i k e l y t h a t t h e emergency d e p a r t -ment p e r f o r m s m u l t i p l e r o l e s among the p a t i e n t s i t s e r v e s . F o r some, t h e emergency d e p a r t m e n t w i l l be t h e c e n t r a l s o u r c e o f c a r e , w h i l e f o r o t h e r s c a r e w i l l be c e n t r a l i z e d e l s e w h e r e and the emergency d e p a r t m e n t w i l l p e r f o r m a more l i m i t e d f u n c t i o n . To t h u s i d e n t i f y d i f f e r e n t t y p e s o f u s e r s i s t o i m p l y t h a t t h e emergency d e p a r t m e n t has d i f f e r e n t i a l r e s p o n s i b i l i t i e s t o i t s p a t i e n t s . M o r e o v e r , d i f f e r e n t i a t i n g t h e m e d i c a l c a r e r e s p o n s i -b i l i t i e s o f t h e emergency d e p a r t m e n t has c o r r e s p o n d i n g i m p l i -c a t i o n s f o r the o r g a n i z a t i o n o f t h e d e p a r t m e n t ( S o l o n , 1966; S o l o n , Sheps & L e e , 1960 b ) . A p p r o p r i a t e o r g a n i z a t i o n a l changes f o r t h e emergency d e p a r t m e n t o f L i o n s Gate H o s p i t a l were c o n -s i d e r e d i n t h e l i g h t o f t h i s f a c i l i t y ' s u n i q u e p a t t e r n s o f u t i l i z a t i o n . 6 CHAPTER I I LITERATURE REVIEW  The Demand f o r Emergency D e p a r t m e n t S e r v i c e s As m e n t i o n e d i n t h e p r e v i o u s c h a p t e r , t h e r i s i n g demand f o r emergency d e p a r t m e n t s e r v i c e s has been w e l l documented i n the l i t e r a t u r e . Between 1954 and 1970 t h e i n c r e a s e i n t h e number o f v i s i t s t o emergency d e p a r t m e n t s i n t h e U n i t e d S t a t e s was much g r e a t e r t h a n t h e i n c r e a s e i n o t h e r measures o f h o s p i t a l u t i l i z a -t i o n . D u r i n g t h i s p e r i o d , t h e number o f h o s p i t a l s i n c r e a s e d by 14 p e r c e n t , t h e number o f i n p a t i e n t beds by 56 p e r c e n t , i n p a t i e n t a d m i s s i o n s by 60 p e r c e n t , and i n p a t i e n t d a y s by 41 p e r c e n t . On t h e o t h e r hand, t h e number o f v i s i t s t o emergency d e p a r t m e n t s r o s e by 353 p e r c e n t . In a d d i t i o n , emergency d e p a r t m e n t v i s i t s as a p e r c e n t a g e o f a l l o u t p a t i e n t d e p a r t m e n t v i s i t s i n c r e a s e d s u b s t a n t i a l l y , f r o m 19 p e r c e n t i n 1954 t o 34 p e r c e n t i n 1970 ( G i b s o n , 1 9 7 3 c ) . T a b l e 1 f u r t h e r i l l u s t r a t e s the d r a m a t i c i n -c r e a s e i n emergency d e p a r t m e n t u t i l i z a t i o n w h i c h has o c c u r r e d i n b o t h t h e U n i t e d S t a t e s and Canada. O b v i o u s l y , t h e l i m i t a t i o n o f T a b l e 1 i s t h a t i t o u t l i n e s t h e p e r c e n t a g e i n c r e a s e i n p a t i e n t v i s i t s w i t h o u t t a k i n g i n t o a c c o u n t changes i n t h e p o p u l a t i o n b a s e . However, e v i d e n c e i n d i c a t e s t h a t t h i s i n c r e a s e i n u t i l i z a t i o n i s n o t d e p e n d e n t upon a c o n c u r r e n t i n c r e a s e i n p o p u l a t i o n . F o r example, t h e i n c r e a s e i n t h e u t i l i z a t i o n o f emergency d e p a r t m e n t s o f 108 h o s p i t a l s i n t h e m e t r o p o l i t a n C h i c a g o a r e a was 112 p e r c e n t between 1960 and 1969. S t a n d a r d i z e d f o r p o p u l a t i o n change, t h e 7 TABLE 1 PERCENTAGE INCREASE IN EMERGENCY DEPARTMENT V I S I T S TO HOSPITALS IN CANADA AND THE UNITED STATES 1 . HOSPITALS Ottawa C i v i c Ottawa, Ont. INVESTIGATOR B a r t h (1967) TIME PERIOD 1962-1966 PERIOD PERCENTAGE IN YEARS INCREASE 48 G r e a t e r N i a g a r a G e n e r a l H o s p i t a l s 66 H o s p i t a l s H o s p i t a l s 71 H o s p i t a l s Humber M e m o r i a l 108 H o s p i t a l s 265 H o s p i t a l s N i a g a r a F a l l s Ont. S a s k a t o o n , Sask. C o l o r a d o New York, N . Y. O h i o T o r o n t o , Ont. M e t r o p o l i t a n C h i c a g o J e s i o n (1970) B a l t z a n (1972) Owens (1966) K r e s k y & S e i f e r t & S i h v o n (1966) G i b s o n (1971) S t r a t i f i e d random sample Skudder 1964-1969 1965-1970 1958-1963 1960-R o s e n f e l d (1969) 1965 1955-J o h n s t o n e (1966) 1962 i n U. S, e t a l . (1961) 1962-1965 I960-1969 1945-1958 10 14 49 63 76' 84 88 102* 112 120 T o r o n t o E a s t G e n e r a l & Or t h o p a e d i c 35 Ho sp i t a l s T o r o n t o , Ont. C o n n e c t i c u t G a l a (1969) Thompson & Webb (1973) 1959-1968 1960-1970 10 11 129 159 S t . Jo seph's H a m i l t o n , Ont. S c a r b o r o u g h S c a r b o r o u g h , C e n t e n a r y Ont. 90 H o s p i t a l s Mid-West & E a s t e r n U.S Vayda e t a l . (1973b) L a y c o c k (1974) S h o r t l i f f e e t a l (1958) 1961-1971 1968-1972 1940-1955 11 16 173* 192 400 • C a l c u l a t e d f r o m d a t a p r e s e n t e d by t h e i n v e s t i g a t o r . ±_. See A p p e n d i x 1 f o r a d d i t i o n a l d a t a r e g a r d i n g t h e p e r c e n t a g e i n c r e a s e i n t h e u t i l i z a t i o n o f emergency d e p a r t m e n t s o f h o s p i t a l s i n t h e U n i t e d S t a t e s . 8 i n c r e a s e i n emergency d e p a r t m e n t v i s i t s i n m e t r o p o l i t a n C h i c a g o was s t i l l 93 p e r c e n t (125 v i s i t s p e r 1,000 p o p u l a t i o n i n 1960 compared t o more t h a n 241 v i s i t s p e r 1,000 p o p u l a t i o n i n 1 9 6 9 ) . M o r e o v e r , s t a n d a r d i z e d f o r p o p u l a t i o n change, t h e i n c r e a s e i n emergency d e p a r t m e n t u t i l i z a t i o n t h r o u g h o u t t h e United S t a t e s was s u b s t a n t i a l - 103 v i s i t s p e r 1,000 p o p u l a t i o n i n 1960 compared t o 192 v i s i t s p e r 1,000 p o p u l a t i o n i n 1969 ( G i b s o n , 1 9 71). A s i m i l a r t r e n d has o c c u r r e d i n Canada. B a l t z a n (1972) e s t i m a t e d t h a t emergency d e p a r t m e n t v i s i t s t o S a s k a t o o n h o s p i t a l s i n c r e a s e d f r o m 0.52 t o 0.72 p e r c a p i t a p e r annum d u r i n g t h e p e r i o d 1965 t o 1970. D u r i n g t h i s p e r i o d , emergency d e p a r t m e n t v i s i t s i n c r e a s e d by 63 p e r c e n t compared t o an i n c r e a s e o f o n l y 18 p e r c e n t i n the p o p u l a t i o n o f t h e C i t y o f S a s k a t o o n . P a t i e n t v i s i t s t o t h e emergency d e p a r t m e n t s o f V a n c o u v e r a r e a h o s p i t a l s a r e e x p e c t e d to show a marked i n c r e a s e . Based on t r e n d s e s t a b l i s h e d from 1964 t o 1968, the Emergency M e d i c a l S e r v i c e s Sub-Committee (1970, p.29) o f t h e G r e a t e r V a n c o u v e r R e g i o n a l H o s p i t a l D i s t r i c t e s t i m a t e d t h a t emergency d e p a r t m e n t u t i l i z a t i o n would i n c r e a s e by 62 p e r c e n t between 1968 and 1976, whereas t h e p o p u l a -t i o n o f the a r e a was e x p e c t e d t o i n c r e a s e by o n l y 17.4 p e r c e n t d u r i n g the same time p e r i o d . S t a n d a r d i z e d f o r p o p u l a t i o n change, i t was e s t i m a t e d t h a t t h e r e would be 237 emergency d e p a r t m e n t v i s i t s p e r 1,000 p o p u l a t i o n i n the V a n c o u v e r a r e a i n 1976, com-p a r e d t o 174 v i s i t s p e r 1,000 p o p u l a t i o n i n 1968. 9 An i n t e r e s t i n g a s p e c t o f t h e demand f o r emergency s e r v i c e s i s t h a t t h e f a c t o r s c o n t r i b u t i n g t o t h i s demand a p p e a r t o be l a r g e l y beyond t h e c o n t r o l o f the emergency d e p a r t m e n t : The h o s p i t a l emergency room c a n n o t c o n t r o l i t s i n t a k e . Any p a t i e n t may p r e s e n t h i m s e l f f o r t r e a t m e n t i n t h e emergency room and must be seen and examined f o r r e a s o n s o f l e g a l l i a b i l i t y . T h i s p a t i e n t - d e t e r m i n e d e n t r y does n o t c h a r a c t e r i z e any o t h e r a s p e c t o f h o s p i t a l a c t i v i t y n o r any o t h e r t r e a t m e n t s e t t i n g i n t h e e n t i r e h e a l t h c a r e s y s t e m ( G i b s o n , 1973c, p . 9 9 ) . The i n a b i l i t y o f t h e emergency d e p a r t m e n t t o c o n t r o l i t s i n -t a k e i s a l s o n o t e d by Roth ( 1 9 7 2 ) : M e d i c a l p e r s o n n e l and o r g a n i z a t i o n s v a r y g r e a t l y i n t h e i r c a p a c i t y t o s e l e c t c l i e n t s . S p e c i a l u n i t s i n t e a c h i n g h o s p i t a l s and s p e c i a l i z e d o u t p a t i e n t c l i n i c s o f t e n a r e a b l e t o r e s t r i c t t h e i r p a t i e n t s t o t h o s e t h e y have i n d i v i d u a l l y s c r e e n e d and s e l e c t e d . The more r u n - o f - t h e - m i l l h o s p i t a l ward or c l i n i c i s l e s s s e l e c t i v e , but s t i l l has a s c r e e n i n g p r o c e s s t o keep o u t c e r t a i n c a t e -g o r i e s o f p a t i e n t s . Of a l l m e d i c a l c a r e u n i t s , p u b l i c h o s p i t a l emergency wards p r o b a b l y e x e r c i s e t h e l e a s t s e l e c t i v i t y o f a l l . Not o n l y a r e t h e y open t o the p u b l i c a t a l l t i m e s w i t h s i g n s p o i n t i n g t h e way, b u t t h e r u l e t h a t e v e r y o n e demanding c a r e must be seen p r o v i d e s no l e g a l " o u t " f o r t h e s t a f f when f a c e d w i t h i n a p p r o p r i a t e o r r e p u g n a n t p a t i e n t s ... ( p . 8 5 2 ) . I n d e e d , much o f t h e demand f o r emergency d e p a r t m e n t s e r v i c e s i s f o r the t r e a t m e n t o f " i n a p p r o p r i a t e " o r n o n - u r g e n t m e d i c a l p r o b l e m s ( i . e . t h e d i s o r d e r i s n o n - a c u t e o r minor i n s e v e r i t y and does n o t r e q u i r e t h e r e s o u r c e s o f an emergency d e p a r t m e n t ) . T a b l e 2 p r e s e n t s d a t a f r o m C a n a d i a n h o s p i t a l s on t h e p e r c e n t a g e o f emergency d e p a r t m e n t v i s i t s w h i c h were f o r t h e t r e a t m e n t o f 10 TABLE 2 PERCENTAGE OF EMERGENCY DEPARTMENT V I S I T S JUDGED TO BE NON-URGENT AT CANADIAN 'HOSPITALS HOSPITALS INVESTIGATOR TIME PERIOD PERCENTAGE NON-URGENT V a n c o u v e r V a n c o u v e r , R o b i n s o n G e n e r a l B. C. e t a l . (1969b) 8 weeks i n 1967-68 23-R o y a l J u b i l e e V i c t o r i a , B . C . A l l e n e t a l . (1973) 6 weeks i n 1971-72 25 G r e a t e r N i a g a r a G e n e r a l N i a g a r a F a l l s 3 weeks Ont. J e s i o n (1970) i n 1969 33 H o s p i t a l f o r S i c k C h i l d r e n T o r o n t o , Ont. Read (1966) 1 month i n 1964 34 * ; S t . J o s e p h 1 s H a m i l t o n , Ont. Vayda et a l . (1973b) 3 weeks i n 1971 34 T o r o n t o E a s t G e n e r a l and O r t h o p a e d i c T o r o n t o , Ont. G a l a (1969) 3 weeks i n 1969 36 Ottawa C i v i c O ttawa, Ont. B a r t h (1967) 1 week i n 1967 42 N o r t h York G e n e r a l T o r o n t o , Ont. B a i n & J o h n s o n (1971) 4 weeks i n 1970 42** H a m i l t o n G e n e r a l Hami1ton, Ont. Vayda e t a l . (1975) 2 weeks i n 1973 44 27 H o s p i t a l s M e t r o p o l i t a n M o n t r e a l F r e c h e t t e (1975) 12 months i n 1972 66 St . Jo s eph's T o r o n t o , Ont. T e g l a s (1969) 1 month i n 1967 70 *Data r e l a t e s o n l y t o c h i l d r e n and a d o l e s c e n t s i n t h e 0-19 y e a r age g r o u p . * * C a l c u l a t e d f r o m d a t a p r e s e n t e d by t h e i n v e s t i g a t o r . i i n o n - u r g e n t p r o b l e m s , w h i l e A p p e n d i x 2 o u t l i n e s d a t a on the p e r -c e n t a g e o f n o n - u r g e n t v i s i t s t o emergency d e p a r t m e n t s i n t h e U n i t e d S t a t e s . T h i s d a t a on n o n - u r g e n t v i s i t s must be v i e w e d w i t h c a u t i o n . V i s i t s were c l a s s i f i e d as n o n - u r g e n t by a m e d i c a l j u d g e , o f t e n t h e t r e a t i n g p h y s i c i a n . I t i s , o f c o u r s e , q u i t e p r o b a b l e t h a t m e d i c a l c o n d i t i o n s w h i c h a r e j u d g e d t o be non-u r g e n t by p r o f e s s i o n a l s may a p p e a r t o be u r g e n t t o t h e p a t i e n t s . F u r t h e r m o r e , s t a n d a r d i z e d c r i t e r i a f o r t h e r a t i n g o f m e d i c a l u r g e n c y does n o t e x i s t i n t h e l i t e r a t u r e - t h e i n v e s t i g a t o r s used a v a r i e t y o f c r i t e r i a t o d e t e r m i n e t h e p e r c e n t a g e o f non-u r g e n t c a s e s . A l s o , d i f f e r e n t j u d g e s may v a r y i n t h e i r i n t e r p r e -t a t i o n of c r i t e r i a f o r r a t i n g m e d i c a l u r g e n c y . N e v e r t h e l e s s , d e s p i t e t h e s e l i m i t a t i o n s , t h e d a t a i n T a b l e 2 i n d i c a t e t h a t much of t h e demand f o r emergency d e p a r t m e n t s e r v i c e s i s f o r t h e t r e a t -ment o f n o n - u r g e n t m e d i c a l p r o b l e m s , and s u g g e s t t h a t t h e emer-gency d e p a r t m e n t has become a m a j o r s o u r c e o f p r i m a r y m e d i c a l 2 . c a r e . -The c o n c l u s i o n t h a t t h e emergency d e p a r t m e n t i s a major s i t e o f p r i m a r y m e d i c a l c a r e i s s u p p o r t e d by numerous o t h e r s t u d i e s . F i r s t , i n a s t u d y o f 15 h o s p i t a l s i n E r i e C o u n t y , New York ( i n c l u d i n g t h e C i t y o f B u f f a l o ) , G i b s o n (1973b) measured the d e g r e e t o w h i c h t h e emergency d e p a r t m e n t s were t r e a t i n g emergen-2_. P r i m a r y c a r e i s n o t y e t c l e a r l y d e f i n e d . However, i t i s o f t e n e q u a t e d w i t h f a m i l y m e d i c i n e , f a m i l y p r a c t i c e , o r g e n e r a l p r a c t i c e ( W i l s o n & N e u h a u s e r , 1974, p . 1 8 9 ) . 12 c i e s as oppo s e d t o s u b s t i t u t i n g f o r an i n a d e q u a t e a m b u l a t o r y c a r e s y s t e m . "... When ea c h of t h e 888 i n t e r v i e w e d p a t i e n t s had been t r e a t e d , t h e a t t e n d i n g p h y s i c i a n was a s k e d : 'What would have been t h e most a p p r o p r i a t e p l a c e f o r t h i s p a t i e n t t o have been t r e a t e d f o r t h i s c o n d i t i o n ? ' ( p . 2 0 ) . " In t h e judgment o f the •• p h y s i c i a n s , t h e emergency d e p a r t m e n t was t h e most a p p r o p r i a t e f a c i l i t y f o r o n l y 51 p e r c e n t o f t h e p a t i e n t s . On t h e o t h e r hand, a p r i v a t e p h y s i c i a n ' s o f f i c e was j u d g e d most a p p r o p r i a t e f o r 24 p e r c e n t o f t h e p a t i e n t s , and a h o s p i t a l o u t p a t i e n t d e p a r t m e n t f o r 20 p e r c e n t . S e c o n d l y , o t h e r s t u d i e s r e p o r t t h a t t h e emergency d e p a r t m e n t i s a s o u r c e o f p r i m a r y m e d i c a l c a r e f o r a l a r g e p r o p o r -t i o n o f t h e p a t i e n t s , b o t h i n Canada (Chipman, 1971) and t h e U n i t e d S t a t e s (Bergman & H a g g e r t y , 1962; I o t t , Webb, Thompson & P e a r s o n , 1974; Lamy, E a r r e l l & Simaam, 1967; Rot h , 1971; S a t i n & D u h l , 1972; W i n g e r t , F r i e d m a n & L a r s o n , 1 9 6 8 ) . In e s s e n c e , t h e us a g e o f t h e emergency d e p a r t m e n t f o r non-u r g e n t or p r i m a r y m e d i c a l c a r e i s t h e r e s p o n s i b i l i t y o f t h e t o t a l m e d i c a l c a r e s y s t e m . Due to t h e l a c k o f a m b u l a t o r y c a r e a l t e r n a -t i v e s , t h e emergency d e p a r t m e n t i s f o r c e d to s e r v e an a d a p t i v e f u n c t i o n f o r t h e w i d e r h e a l t h c a r e s y s t e m ( G i b s o n , 1973c) . T h i s a d a p t i v e r o l e of t h e emergency d e p a r t m e n t a p p r o x i m a t e s t h e r o l e o f a 24-hour g e n e r a l p r a c t i t i o n e r , an o u t p a t i e n t d e p a r t m e n t o r a community h e a l t h c e n t r e . 13 F a c t o r s C o n t r i b u t i n g t o t h e Demand f o r Emergency D e p a r t m e n t S e r v i c e s The i n c r e a s e i n demand f o r emergency d e p a r t m e n t s e r v i c e s has been a t t r i b u t e d t o a v a r i e t y o f f a c t o r s : (1) The s h o r t a g e o f g e n e r a l p r a c t i t i o n e r s , t h e r e l u c t a n c e o f f a m i l y p h y s i c i a n s t o make house c a l l s , and t h e g r o w i n g t e n d e n c y o f p h y s i c i a n s t o s p e c i a l i z e and t o a r r a n g e o f f i c e h o u r s by a p p o i n t m e n t o n l y . C o n s e q u e n t l y , p a t i e n t s . h a v e d i f f i c u l t y i n l o c a t i n g a p h y s i c i a n , e s p e c i a l l y on weekends, h o l i d a y s and a t n i g h t . (2) M u l t i p l e d i a g n o s t i c f a c i l i -t i e s a r e r e a d i l y a v a i l a b l e a t t h e h o s p i t a l . As a r e s u l t , p h y s i -c i a n s u t i l i z e t h e emergency d e p a r t m e n t t o p e r f o r m p r o c e d u r e s f o r m e r l y done i n t h e i r o f f i c e s . (3) C o n v e n i e n c e m o t i v e s o f b o t h t h e p h y s i c i a n and t h e p a t i e n t . (4) The l a r g e amount o f g e o g r a p h i c m o b i l i t y i n our s o c i e t y w h i c h i n t e r r u p t s t h e r e l a t i o n s h i p between p a t i e n t and p h y s i c i a n . (5) H e a l t h i n s u r a n c e p l a n s i n t h e U n i t e d S t a t e s w h i c h c o v e r emergency d e p a r t m e n t v i s i t s , b u t n o t o f f i c e v i s i t s o r house c a l l s . (6) The p u b l i c ' s a c c e p t a n c e o f the h o s p i -t a l as t h e h e a l t h c e n t r e o f t h e community ( A t t e r b u r y , W e i l & D o n n e l l , 1968; C h a i t o n , 1975; G i b s o n , 1973a; K r a u s e , 1976; Vaughan & Gamester, 1966a) . U n f o r t u n a t e l y , t h e r e l a t i v e i m p o r t a n c e o f the above f a c t o r s has n o t been e s t a b l i s h e d . N o n e t h e l e s s , a few s t u d i e s have examined t h e m o t i v e s o f p a t i e n t s f o r s e e k i n g t r e a t m e n t a t emer-gency d e p a r t m e n t s . The most e x t e n s i v e s t u d y , by Vaughan and Gamester (1966a), a d d r e s s e s i t s e l f t o t h e c i r c u m s t a n c e s and r e a s o n s b e h i n d emergency d e p a r t m e n t v i s i t s t o 22 h o s p i t a l s i n 14 M i c h i g a n . As shown i n T a b l e 3, 46.4 p e r c e n t o f the p a t i e n t s a t t e m p t e d t o c a l l a p r i v a t e p h y s i c i a n b e f o r e t h e i r emergency d e p a r t m e n t v i s i t , w h i l e 53.6 p e r c e n t went d i r e c t l y t o t h e h o s p i -t a l . In t o t a l , 34.8 p e r c e n t o f t h e p a t i e n t s were r e f e r r e d t o t h e h o s p i t a l by a p r i v a t e p h y s i c i a n (Groups 1 and 2 ) , w h i l e 34.5 p e r c e n t u t i l i z e d t h e emergency d e p a r t m e n t b e c a u s e t h e y e i t h e r t r i e d b ut f a i l e d t o c o n t a c t a p h y s i c i a n or f e l t t h a t t h e i r p h y s i c i a n was n o t a v a i l a b l e (Groups 3 and 4 ) . Thus, 69.3 p e r c e n t o f t h e p a t i e n t s d e n o t e d t h a t t h e i r p r i m a r y r e a s o n f o r s e e k i n g c a r e a t t h e emergency d e p a r t m e n t was r e l a t e d t o a p r i v a t e p h y s i -c i a n , h i s a v a i l a b i l i t y , o r method o f p r a c t i c e . "These p a t i e n t r e s p o n s e s s t r o n g l y i n d i c a t e t h a t t h e p h y s i c i a n was t h e key f i g u r e i n emergency room u t i l i z a t i o n ... A l l o t h e r r e a s o n s , as r e p r e -s e n t e d by Groups 5 t h r o u g h 11, were m i n o r by c o m p a r i s o n (Vaughan & Gamester, 1966a, p . 4 6 ) . " O t h e r i n v e s t i g a t o r s have s o u g h t i n f o r m a t i o n c o n c e r n i n g t h e e x t e n t t o w h i c h p r i v a t e p h y s i c i a n s c o n t r i b u t e t o t h e demand f o r emergency d e p a r t m e n t s e r v i c e s . I t s h o u l d be c a u t i o n e d , however, t h a t p a t i e n t m o t i v a t i o n f o r s e e k i n g m e d i c a l t r e a t m e n t i s more c o m p l i c a t e d t h a n t h e s e s t u d i e s encompass. F u r t h e r m o r e , t h e s t u d i e s v a r y a c c o r d i n g t o whether d a t a r e l a t e d t o t h e p h y s i c i a n s ' r e l a t i v e c o n t r i b u t i o n t o emergency d e p a r t m e n t v i s i t s i n c l u d e , t h o s e p a t i e n t s who do n o t have a f a m i l y d o c t o r . F o u r s t u d i e s t e n d t o s u p p o r t th e c o n c l u s i o n t h a t p r i v a t e p h y s i c i a n s a r e key f i g u r e s i n emergency d e p a r t m e n t u t i l i z a t i o n . 15 TABLE 3 PERCENTAGE DISTRIBUTION OF MICHIGAN PATIENTS BY ATTEMPT TO CALL PHYSICIAN BEFORE EMERGENCY DEPARTMENT V I S I T P h y s i c i a n C a l l e d B e f o r e V i s i t t o H o s p i t a l PERCENTAGE DISTRIBUTION (46.4) P h y s i c i a n I n s t r u c t e d P a t i e n t t o Go t o H o s p i t a l 16.3 P h y s i c i a n I n s t r u c t e d P a t i e n t t o Meet Him a t H o s p i t a l 18.5 P a t i e n t T r i e d But F a i l e d t o Reach P r i v a t e P h y s i c i a n 11.6 P h y s i c i a n Not C a l l e d B e f o r e V i s i t t o H o s p i t a l (53.6) 4. P a t i e n t B e l i e v e d P r i v a t e P h y s i c i a n Was Not A v a i l a b l e 22.9 5. Immediate C a r e o r H o s p i t a l F a c i l i t i e s Were R e q u i r e d 7.9 6. P a t i e n t Taken I n v o l u n t a r i l y by P o l i c e , Ambulance, e t c . 3.2 7. P a t i e n t Sent t o H o s p i t a l by E m p l o y e r , T e a c h e r , e t c . 5.8 8. P a t i e n t Became 111 W h i l e a t H o s p i t a l 3.1 9. H o s p i t a l i s More C o n v e n i e n t or No F a m i l y P h y s i c i a n 6.2 10. I n s u r a n c e C o v e r a g e F o r H o s p i t a l C a r e 0.9 11. O t h e r Reasons 3.6 16 A t Richmond M e m o r i a l H o s p i t a l i n V i r g i n i a , 23 p e r c e n t o f t h e emergency d e p a r t m e n t p a t i e n t s d i d n o t have a f a m i l y p h y s i c i a n , 16 p e r c e n t s t a t e d t h a t t h e i r f a m i l y p h y s i c i a n was u n a v a i l a b l e f o r t r e a t m e n t , and 10 p e r c e n t were r e f e r r e d t o t h e emergency d e p a r t -ment by t h e i r f a m i l y d o c t o r . "Thus, 49 p e r c e n t o f a l l v i s i t s r e s u l t e d from t h e p a t i e n t s e i t h e r n o t h a v i n g a f a m i l y p h y s i c i a n o r n o t h a v i n g a c c e s s t o t h e i r f a m i l y p h y s i c i a n a t t h e time t h e y were s e e k i n g m e d i c a l c a r e (Wood, P r y b i l & Simpson, 1974, p . 4 6 2 ) . " R e g r e t t a b l y , i t i s n o t c l e a r whether the 16 p e r c e n t o f t h e p a t i e n t s who s t a t e d t h a t t h e i r f a m i l y p h y s i c i a n was u n a v a i l a b l e f o r t r e a t m e n t i n c l u d e s o n l y t h o s e p a t i e n t s who t r i e d b u t f a i l e d t o c o n t a c t t h e i r d o c t o r o r a l s o t h o s e p a t i e n t s who d i d n o t a t t e m p t t o c o n t a c t t h e i r d o c t o r b e c a u s e t h e y b e l i e v e d t h a t he was n o t a v a i l a b l e . W alker (1975a; 1975b), i n a s t u d y a t S o u t h Community H o s p i t a l i n Oklahoma C i t y , d e t e r m i n e d t h a t 12 p e r c e n t o f t h e p a t i e n t s were r e f e r r e d t o t h e emergency d e p a r t m e n t by t h e i r f a m i l y p h y s i c i a n , 10 p e r c e n t were t o l d t o meet t h e i r f a m i l y p h y s i c i a n i n t h e emer-gency d e p a r t m e n t , w h i l e a n o t h e r 11 p e r c e n t o f t h e p a t i e n t s e i t h e r t r i e d b u t f a i l e d t o c o n t a c t t h e i r p h y s i c i a n o r were u n s a t i s f i e d w i t h t h e i r p h y s i c i a n ' s i n s t r u c t i o n s . " C o n s e q u e n t l y , t h e p r i v a t e p h y s i c i a n s i n t h i s community e n c o u r a g e d 35 p e r c e n t ( s i c ) o f t h e emergency s e r v i c e usage e i t h e r by d i r e c t or i n d i r e c t i n f l u e n c e ( Walker, 1975a, p . 4 7 ) . " In t h i s s t u d y , the i n d i r e c t i n f l u e n c e o f t h e p h y s i c i a n s has been u n d e r e s t i m a t e d s i n c e the d a t a does n o t i n c l u d e t h o s e p a t i e n t s who d i d n o t a t t e m p t t o c o n t a c t a p r i v a t e d o c t o r b e c a u s e t h e y f e l t t h a t one was u n a v a i l a b l e . T h i s u n d e r -e s t i m a t i o n may be s u b s t a n t i a l s i n c e 66 p e r c e n t o f t h e p a t i e n t s went d i r e c t l y t o t h e emergency d e p a r t m e n t w i t h o u t a t t e m p t i n g t o 17 c o n t a c t a p r i v a t e d o c t o r . Two s t u d i e s examined why s e l f - r e f e r r e d p a t i e n t s came d i r e c t l y t o t h e emergency d e p a r t m e n t . A t Yale-New Haven H o s p i t a l i n C o n n e c t i c u t , 54.7 p e r c e n t o f t h e emergency d e p a r t m e n t p a t i e n t s were s e l f - r e f e r r a l s . T h i r t y - t h r e e p e r c e n t o f t h e s e s e l f - r e f e r r e d p a t i e n t s s p e c i f i e d t h a t t h e d e c i s i o n t o come t o t h e emergency s e r -v i c e r e p r e s e n t e d t h e i r own p e r c e p t i o n o f t h e b e s t way t o r e s p o n d t o t h e m e d i c a l p r o b l e m . On t h e o t h e r hand, 27.7 p e r c e n t i n d i c a t e d t h a t t h e y l a c k e d a r e g u l a r r e l a t i o n s h i p w i t h a p r i v a t e p h y s i c i a n , w h i l e a n o t h e r 20.5 p e r c e n t m e n t i o n e d t h a t t h e i r p r i v a t e p h y s i c i a n was n o t a v a i l a b l e . Thus, " d i f f i c u l t i e s i n o b t a i n i n g p r i v a t e m e d i -c a l c a r e were p r o m i n e n t among t h e r e a s o n s f o r d i r e c t s e l f - r e f e r r a l (Weinerman, R a t n e r , R o b b i n s & L a v e n h a r , 1966, p . 1 0 4 6 ) . " Once a g a i n , however, i t i s n o t c l e a r whether t h o s e p a t i e n t s who men-t i o n e d t h a t t h e i r p r i v a t e p h y s i c i a n was u n a v a i l a b l e i n c l u d e s b o t h t h o s e who t r i e d b u t f a i l e d t o c o n t a c t t h e i r p h y s i c i a n , and t h o s e who d i d n o t a t t e m p t t o c o n t a c t t h e i r p h y s i c i a n b e c a u s e t h e y b e l i e v e d t h a t he was n o t a v a i l a b l e . P e r h a p s some of t h e 33 p e r c e n t o f t h e s e l f - r e f e r r a l s who f e l t t h a t a v i s i t t o t h e emergency d e p a r t m e n t r e p r e s e n t e d t h e b e s t way t o h a n d l e th e m e d i c a l p r o b l e m r e a c h e d t h i s d e c i s i o n b e c a u s e t h e y f e l t t h a t a p r i v a t e p h y s i c i a n was u n a v a i l a b l e a t t h e t i m e . S e l f - r e f e r r e d p a t i e n t s (52.5 p e r c e n t o f the t o t a l number o f p a t i e n t s ) were a l s o a s k e d why t h e y came d i r e c t l y t o the emergency d e p a r t m e n t a t S t . J o s e p h ' s H o s p i t a l i n H a m i l t o n , O n t a r i o . In t h i s s t u d y , 704 r e s p o n s e s were coded from 598 s e l f - r e f e r r e d p a t i e n t s 18 s i n c e some p a t i e n t s gave more t h a n one r e a s o n . The most f r e -q u e n t r e s p o n s e g i v e n by t h e s e I f - r e f e r r a l s was t h a t t h e time was " o u t o f d o c t o r ' s p r a c t i c e h o u r s " (26.1 p e r c e n t o f r e s p o n s e s ) . Some s e l f - r e f e r r a l s m e n t i o n e d t h a t t h e y e i t h e r c o u l d n o t g e t an a p p o i n t m e n t w i t h a p h y s i c i a n or e l s e would have had a l o n g w a i t f o r an a p p o i n t m e n t (9.5 p e r c e n t o f r e s p o n s e s ) , o t h e r s i n d i c a t e d t h a t t h e y had no f a m i l y d o c t o r (8.4 p e r c e n t o f r e s p o n s e s ) , w h i l e o t h e r s s t a t e d t h a t a d o c t o r had p r e v i o u s l y s u g g e s t e d g o i n g t o t h e emergency d e p a r t m e n t f o r a p r o b l e m o f t h i s k i n d (4.4 p e r c e n t o f r e s p o n s e s ) (Vayda, Gent & P a i s l e y , 1 9 73b). In t o t a l , 48.4 p e r c e n t o f t h e r e s p o n s e s f r om t h e s e l f - r e f e r r e d p a t i e n t s a r e r e l a t e d t o d i f f i c u l t i e s i n o b t a i n i n g m e d i c a l c a r e from p r i v a t e p h y s i c i a n s . I t i s u n f o r t u n a t e t h a t t h e c a t e g o r y o f r e s p o n s e s l a b e l e d " o u t o f d o c t o r ' s p r a c t i c e h o u r s " was n o t more c l e a r l y d e f i n e d so t h a t i t c o u l d be d e t e r m i n e d whether p a t i e n t s g i v i n g t h i s r e s p o n s e a c t u a l l y a t t e m p t e d t o c o n t a c t a p h y s i c i a n . In c o n t r a s t t o t h e above r e s u l t s , one C a n a d i a n s t u d y does n o t s u p p o r t t h e c o n c l u s i o n t h a t p r i v a t e p h y s i c i a n s a r e key f i g u r e s i n emergency d e p a r t m e n t u t i l i z a t i o n . B a l t z a n (1972) examined d o c t o r n o n - a v a i l a b i 1 i t y , and f o u n d t h a t o n l y 6.8 p e r c e n t o f emergency d e p a r t m e n t p a t i e n t s d i d n o t have a f a m i l y p h y s i c i a n and o n l y 16 p e r c e n t o f t h e p a t i e n t s who a t t e m p t e d t o c o n t a c t t h e i r p h y s i c i a n were n o t s u c c e s s f u l . On t h e b a s i s o f t h e s e f i n d i n g s , B a l t z a n c o n c l u d e d t h a t t h e v a r i o u s forms o f d o c t o r n o n - a v a i l a b i l i t y a r e not f a c t o r s w h i c h have c o n t r i b u t e d t o the i n c r e a s e d demand f o r emergency d e p a r t m e n t s e r v i c e s a t S t . P a u l ' s H o s p i t a l i n S a s k a t o o n . 19 I t i s o b v i o u s , however, t h a t t h i s study u n d e r e s t i m a t e s t h e i n f l u -ence o f d o c t o r n o n - a v a i l a b i l i t y . As d e f i n e d by B a l t z a n , " d o c t o r n o n - a v a i l a b i l i t y may t a k e one o f two f o r m s : the p a t i e n t may n o t have a f a m i l y p h y s i c i a n , or he may n o t be a b l e t o c o n t a c t t h e one he does have ;(pp.252 & 2 5 5 ) . " As o p e r a t i o n a l i z e d by B a l t z a n , t h i s d e f i n i t i o n o f d o c t o r n o n - a v a i l a b i l i t y i g n o r e s t h e f a c t t h a t t h e l a t t e r form has two components; " a c t u a l n o n - a v a i l a b i l i t y " ( i . e . , p a t i e n t s t r y b u t f a i l t o c o n t a c t t h e i r f a m i l y p h y s i c i a n ) and " p e r c e i v e d n o n - a v a a j l a b i l i t y " ( i . e . , p a t i e n t s do n o t a t t e m p t t o c o n t a c t t h e i r f a m i l y p h y s i c i a n b e c a u s e t h e y b e l i e v e t h a t he i s n o t a v a i l a b l e ) . A t S t . P a u l ' s H o s p i t a l , 39.7 p e r c e n t o f t h e emer-gency d e p a r t m e n t p a t i e n t s d i d n o t a t t e m p t t o c o n t a c t t h e i r f a m i l y d o c t o r . B a l t z a n f a i l s t o d e t e r m i n e how many o f t h e s e p a t i e n t s went d i r e c t l y t o t h e emergency d e p a r t m e n t b e c a u s e o f " p e r c e i v e d n o n - a y a i l a b i l i t y " o f t h e i r f a m i l y d o c t o r . The e x t e n t t o w h i c h p r i v a t e p h y s i c i a n s c o n t r i b u t e t o t h e demand f o r emergency d e p a r t m e n t s e r v i c e s depends upon s e v e r a l f a c t o r s , i n c l u d i n g t h e amount o f p h y s i c i a n r e f e r r a l t o t h e emer-gency d e p a r t m e n t , a c t u a l d o c t o r n o n - a v a i l a b i l i t y and p e r c e i v e d d o c t o r n o n - a v a i l a b i l i t y . In a d d i t i o n , some a u t h o r s i n c l u d e t h e p a t i e n t ' s l a c k o f a f a m i l y d o c t o r ; T a b l e 4 i l l u s t r a t e s t h a t one o f t h e s e f a c t o r s , t h e amount of p h y s i c i a n r e f e r r a l , v a r i e s w i d e l y f r o m h o s p i t a l t o h o s p i t a l . T h e v d a t a s u g g e s t t h e p o s s i b i l i t y t h a t t h e o t h e r f a c t o r s may a l s o v a r y w i d e l y ; and, t h u s , t h e e x t e n t t o w h i c h p r i v a t e p h y s i c i a n s c o n t r i b u t e t o t h e demand f o r emergency d e p a r t m e n t s e r v i c e s may d i f f e r f r o m h o s p i t a l t o h o s p i t a l . 20 TABLE 4 PATIENTS •' SOURCE OF REFERRAL TO THE EMERGENCY DEPARTMENT INVESTIGATOR C a n a d i a n H o s p i t a l s B a r t h , N. K. (1967) B a i n , S. & J o h n s o n , S (1971) • R o b i n s o n , G. C. e t a l (1969b)* PHYSICIAN REFERRALS (INCLUDING PHYSICIAN'S STAFF) 34% 22% S E L F -R E F E R R A L S ( I N C L U D I N G O T H E R R E L A T I V E S ( I N C L U D I N G A N D F R I E N D S U N S P E C I F I E D ) 45% 49% 59% 48% 17% 19% 6% U n i t e d S t a t e s H o s p i t a l s Webb, M. L. (1969) J a c o b s , A. R. e t a l . (1971) K l u g e , D. N. e t a l . (1965) Weinerman, E. R. e t a l (1966) White, H. A. & O'Connor, P. A. (1970) Duncan, M. (1962 ) Reed, J . I . & Reader, G. G. (1967) 11% 6% 23% 14% 32% 29% 9% 67% 77% 64% 65% 57% 52% 80% 21% 18% 13% 21% 11% 19% 11% * D a t a r e l a t e s o n l y t o c h i l d r e n and a d o l e s c e n t s i n t h e 0-19 y e a r age g r o u p . 21 The s t u d i e s r e v i e w e d i n t h i s s e c t i o n p r o v i d e some u s e f u l i n f o r m a t i o n c o n c e r n i n g t h e m o t i v e s o f p a t i e n t s f o r s e e k i n g m e d i -c a l c a r e . N o n e t h e l e s s , t h e s e s t u d i e s a r e e x p l o r a t o r y i n n a t u r e ; and, w i t h t h e p o s s i b l e e x c e p t i o n o f Vaughan and Gamester (1966a), f a i l t o encompass the i n t r i c a t e and complex n a t u r e o f p a t i e n t m o t i v a t i o n f o r s e e k i n g t r e a t m e n t a t emergency d e p a r t m e n t s . More r e s e a r c h i s needed b e f o r e one can d e t e r m i n e t h e r e l a t i v e i m p o r -t a n c e o f t h e v a r i o u s f a c t o r s c o n t r i b u t i n g t o t h e i n c r e a s e d demand f o r emergency d e p a r t m e n t s e r v i c e s . I n d e e d , the r e l a t i v e i m p o r -t a n c e o f t h e f a c t o r s w i l l l i k e l y v a r y from h o s p i t a l t o h o s p i t a l . As n o t e d by G i b s o n ( 1 9 7 4 c ) , "... we know l i t t l e o f p a t i e n t m o t i v a -t i o n i n c h o o s i n g one emergency d e p a r t m e n t o v e r a n o t h e r o r an emer-gency d e p a r t m e n t o v e r an a l t e r n a t i v e a m b u l a t o r y c a r e s i t e ... ( p . 1 6 ) . " P a t i e n t s ' O v e r a l l M e d i c a l C a r e P a t t e r n s In o r d e r t o u n d e r s t a n d t h e r o l e o f the emergency d e p a r t m e n t i n t h e h e a l t h c a r e s y s t e m , one must examine how t h i s f a c i l i t y f i t s i n t o t h e p a t i e n t s ' o v e r a l l m e d i c a l c a r e p a t t e r n s . As n o t e d by Lee, S o l o n & Sheps (1960), "the f u n c t i o n o f t h e emergency u n i t may be v e r y d i f f e r e n t f o r p a t i e n t s whose v i s i t s a r e o u t w a r d l y f o r t h e same p u r p o s e , but whose t o t a l p a t t e r n s o f o b t a i n i n g m e d i c a l c a r e a r e d i f f e r e n t (p.101) ." U n f o r t u n a t e l y , most r e s e a r c h t e n d s t o n e g l e c t t h e r e l a t i o n -s h i p o f t h e emergency d e p a r t m e n t t o t h e p a t i e n t s ' o t h e r s o u r c e s of c a r e . "The t y p i c a l s t u d y f u r n i s h e s a t u n n e l - v i s i o n a c c o u n t of t h e emergency u n i t ' s u s e , t e n d i n g t o d e a l w i t h i t q u i t e i n i s o l a t i o n ( S o l o n & R i g g , 1972, p . 6 1 ) . " 22 N o n e t h e l e s s , some r e s e a r c h has examined o t h e r s o u r c e s o f m e d i c a l c a r e used by emergency d e p a r t m e n t p a t i e n t s . S e v e r a l i n v e s t i g a t o r s i n q u i r e d o f p a t i e n t s , "Where do you u s u a l l y go when you need m e d i c a l h e l p ? " In e a c h s t u d y , p r i v a t e p h y s i c i a n s were most f r e q u e n t l y m e n t i o n e d as the u s u a l s o u r c e o f m e d i c a l c a r e , a l t h o u g h t h e p r o p o r t i o n o f p a t i e n t s g i v i n g t h i s r e s p o n s e v a r i e d c o n s i d e r a b l y . A t Yale-New Haven H o s p i t a l i n C o n n e c t i c u t , p r i v a t e p h y s i c i a n s were t h e u s u a l s o u r c e o f c a r e f o r 36.6 p e r c e n t o f t h e p a t i e n t s , the emergency s e r v i c e f o r 24.6 p e r c e n t , h o s p i t a l c l i n i c s f o r 13.2 p e r c e n t , w h i l e 15.4 p e r c e n t o f t h e emergency d e p a r t m e n t p a t i e n t s had no c o n s i s t e n t p a t t e r n o f m e d i c a l c a r e (Weinerman, R a t n e r , R o b b i n s , & L a v e n h a r , 1 9 6 6 ) . In a s t u d y o f 24 emergency d e p a r t m e n t s i n 22 h o s p i t a l s i n m e t r o p o l i t a n B a l t i m o r e , Webb (1969) f o u n d t h a t p r i v a t e p h y s i c i a n s were most f r e q u e n t l y men-t i o n e d as t h e u s u a l s o u r c e o f c a r e (43.9 p e r c e n t o f p a t i e n t s ) , f o l l o w e d by emergency d e p a r t m e n t s (31.8 p e r c e n t ) and h o s p i t a l c l i n i c s (13.2 p e r c e n t ) . A r o n o v i t c h (1973) s t u d i e d two non-m e t r o p o l i t a n and p r e d o m i n a n t l y r u r a l a r e a s i n M a r y l a n d , i n v o l v i n g f o u r h o s p i t a l s i n Wes.tern M a r y l a n d and f o u r E a s t e r n Shore h o s p i -t a l s . In t h i s s t u d y , p r i v a t e p h y s i c i a n s were t h e u s u a l s o u r c e o f c a r e f o r t h e m a j o r i t y o f t h e emergency department p a t i e n t s (72.7 p e r c e n t o f E a s t e r n Shore and 67.1 p e r c e n t o f W e s t e r n M a r y l a n d p a t i e n t s ) . Emergency d e p a r t m e n t s were t h e u s u a l s o u r c e o f c a r e f o r t h e n e x t l a r g e s t group o f p a t i e n t s (18.7 p e r c e n t and 24.8 p e r c e n t r e s p e c t i v e l y o f E a s t e r n Shore and Western M a r y l a n d p a t i e n t s ) . In Canada, B a a r s (1969) f o u n d t h a t p r i v a t e p h y s i c i a n s were t h e u s u a l s'ource o f c a r e f o r t h e m a j o r i t y o f emergency d e p a r t m e n t p a t i e n t s a t R i v e r s i d e H o s p i t a l i n Ottawa. S e v e n t y - S i x 23 p e r c e n t o f t h e p a t i e n t s r e l i e d on a f a m i l y p h y s i c i a n f o r u s u a l m e d i c a l a d v i c e , w h i l e o n l y 11 p e r c e n t r e l i e d on t h e emergency d e p a r t m e n t . In a more d e t a i l e d a n a l y s i s , T o r r e n s and Yedvab (1967;1970) examined t h e m e d i c a l c a r e p a t t e r n s o f emergency d e p a r t m e n t p a t i e n t s a t f o u r New Y o r k C i t y a r e a h o s p i t a l s . Two o f t h e h o s p i t a l s were l o c a t e d i n t h e c e n t r a l u r b a n a r e a o f t h e c i t y ( i n M a n h a t t a n ) , one was l o c a t e d i n a r e s i d e n t i a l u r b a n a r e a ( w i t h i n t h e c i t y l i m i t s , b u t some d i s t a n c e from th e b u s i n e s s and c o m m e r c i a l c e n t e r ) and one was l o c a t e d i n a s u b u r b a n a r e a (on Long I s l a n d ) . T o r r e n s and Yedvab (1967) d e t e r m i n e d t h e p a t i e n t s ' p r i m a r y s i t e o f m e d i c a l c a r e d u r i n g t h e p r e v i o u s y e a r - i . e . , t h e f a c t i l i t y i n w h i c h more than h a l f o f t h e i r a m b u l a t o r y d o c t o r - p a t i e n t c o n t a c t s had t a k e n p l a c e . The d a t a r e v e a l e d t h a t a p r i v a t e p h y s i c i a n ' s o f f i c e was t h e p r i m a r y s i t e o f c a r e f o r 30 p e r c e n t o f t h e p a t i e n t s , an o u t -p a t i e n t c l i n i c f o r 20.5 p e r c e n t , and an emergency d e p a r t m e n t f o r 12 p e r c e n t . A..primary site-.of c a r e c o u l d n o t be d e t e r m i n e d f o r 31 p e r c e n t o f t h e p a t i e n t s , s i n c e t h e y had r e c e i v e d no a m b u l a t o r y m e d i c a l c a r e i n t h e y e a r p r i o r t o t h e s t u d y . (Thus, 43 p e r c e n t o f the p a t i e n t s e i t h e r u t i l i z e d an emergency d e p a r t m e n t as t h e i r p r i m a r y s i t e o f c a r e o r had t h e i r f i r s t a m b u l a t o r y p h y s i c i a n -c o n t a c t w i t h i n a y e a r i n an emergency d e p a r t m e n t . ) M o r e o v e r , T o r r e n s and Yedvab (1967) d i s c o v e r e d t h a t the i m p o r t a n c e o f t h e emergency d e p a r t m e n t i n t h e p a t t e r n s o f c a r e o f the p a t i e n t s v a r i e d a c c o r d i n g t o t h e l o c a t i o n o f t h e h o s p i t a l . The emergency d e p a r t m e n t s o f t h e two c e n t r a l u r b a n h o s p i t a l s were the p r i m a r y s i t e o f c a r e f o r 16 p e r c e n t and 15 p e r c e n t o f t h e i r p a t i e n t s 24 r e s p e c t i v e l y , w h e r e a s t h e f i g u r e s w e r e o n l y 8 p e r c e n t f o r t h e r e s i d e n t i a l u r b a n h o s p i t a l a n d 5 p e r c e n t f o r t h e s u b u r b a n h o s -p i t a l • A l t h o u g h i d e n t i f y i n g t h e p a t i e n t s ' u s u a l o r p r i m a r y s o u r c e o f m e d i c a l c a r e p r o v i d e s i m p o r t a n t e x p l o r a t o r y i n f o r m a t i o n , t h e r o l e o f t h e e m e r g e n c y d e p a r t m e n t i n t h e h e a l t h c a r e s y s t e m i s < m o r e c o m p l i c a t e d t h a n e n v i s i o n e d b y t h i s s i n g l e c r i t e r i o n . A s p o i n t e d o u t b y T o r r e n s a n d Y e d v a b ( 1 9 6 7 ) , t h e c r i t e r i o n "... l e a v e s m u ch t o be d e s i r e d i n a s s e s s i n g t h e q u a l i t a t i v e i m p o r t a n c e o f e a c h s i t e o f c a r e ... ( p . 1 1 3 ) . " A m o r e e x t e n s i v e v i e w o f t h e r o l e o f t h e e m e r g e n c y d e p a r t -m e n t i s o f f e r e d b y t w o s t u d i e s w h i c h u t i l i z e b o t h q u a n t i t a t i v e a n d q u a l i t a t i v e c r i t e r i a . F i r s t , S o l o n a n d R i g g ( 1 9 7 2 ) c o l l e c t e d d a t a f r o m t h e e m e r g e n c y d e p a r t m e n t s o f a n i n n e r - c i t y a n d a^si-uburban h o s p i t a l i n t h e P i t t s b u r g a r e a , a n d d e t e r m i n e d t h e p a t i e n t s ' v o l u m e a n d c e n t r a l s o u r c e s o f c a r e . T h e c e n t r a l s o u r c e i s t h e m o s t i m p o r t a n t f a c i l i t y o r p h y s i c i a n ( i n t e r m s o f c o n t i n u i n g t r u s t o r r e l i a n c e ) t o whom t h e p a t i e n t s t u r n w h e n t h e y n e e d m e d i c a l a d v i c e o r c a r e . T h e v o l u m e s o u r c e i s w h e r e t h e p a t i e n t s make t h e i r g r e a t e s t n u m b e r o f c o n t a c t s . T h e r e s u l t s c l e a r l y s h o w t h e p r e d o m i n a n t p l a c e o c c u p i e d b y p r i v a t e p h y s i c i a n s i n t h e m e d i c a l c a r e p a t t e r n s o f t h e p a t i e n t s a t b o t h h o s p i t a l s . P r i v a t e p h y s i -c i a n s w e r e m o s t o f t e n s p e c i f i e d a s t h e c e n t r a l s o u r c e o f c a r e ( 8 5 p e r c e n t o f S u b u r b a n a n d 59 p e r c e n t o f I n n e r - C i t y p a t i e n t s ) , a s w e l l a s t h e v o l u m e s o u r c e o f c a r e ( 9 0 p e r c e n t a n d 63 p e r c e n t r e s p e c t i v e l y o f S u b u r b a n a n d I n n e r - C i t y p a t i e n t s ) . I n c o n t r a s t , 25 o n l y a s m a l l p r o p o r t i o n o f p a t i e n t s u s e d t h e e m e r g e n c y d e p a r t m e n t a s t h e i r c e n t r a l s o u r c e o f c a r e (4 p e r c e n t o f I n n e r - C i t y a n d 1 p e r c e n t o f S u b u r b a n p a t i e n t s ) , o r t h e i r v o l u m e s o u r c e o f c a r e (5 p e r c e n t a n d 2 p e r c e n t r e s p e c t i v e l y o f I n n e r - C i t y a n d S u b u r b a n p a t i e n t s ) . I n a d d i t i o n , S o l o n a n d R i g g e x a m i n e d o t h e r a s p e c t s o f t h e p a t i e n t s ' m e d i c a l c a r e p a t t e r n s , s u c h a s t h e i r " c o n f i g u r a t i o n o f c a r e " (a c o n c e p t u a l f r a m e w o r k w h i c h d e s i g n a t e s t h e p a t i e n t s ' s i g n i f i c a n t c o n t i n u i n g s o u r c e s o f c a r e a n d i n t e r r e l a t e s t h e i r s o u r c e s o f g e n e r a l m e d i c a l a n d s p e c i a l t y c a r e ) . On t h e b a s i s o f a l l a v a i l a b l e i n f o r m a t i o n , S o l o n a n d R i g g c o n c l u d e d t h a t t h e e m e r -g e n c y d e p a r t m e n t o c c u p i e d a p e r i p h e r a l p l a c e i n t h e t o t a l p a t t e r n o f c a r e f o r t h e m a j o r i t y o f t h e p a t i e n t s ( 6 9 p e r c e n t o f I n n e r - C i t y a n d 78 p e r c e n t o f S u b u r b a n p a t i e n t s ) . On t h e o t h e r h a n d , f o r n o t i n s u b s t a n t i a l n u m b e r s , t h e e m e r g e n c y d e p a r t m e n t "... i s j u d g e d t o h a v e a c o n t i n u i n g a n d i m p o r t a n t r o l e . S i g n i f i c a n t l y m o r e o f t h e I n n e r - C i t y e m e r g e n c y p a t i e n t s s e e m e d t o make c o n t i n u i n g a n d i m p o r -t a n t u s e o f t h e e m e r g e n c y u n i t a s p a r t o f t h e i r r e g u l a r m e d i c a l c a r e p a t t e r n (14 p e r c e n t a s c o m p a r e d t o S u b u r b a n ' s 7 p e r c e n t ) ( S o l o n a n d R i g g , 1 9 7 2 , p . 6 8 ) . " S t r a t m a n n a n d U l l m a n ( 1 9 7 5 ) d e t e r m i n e d i n d i v i d u a l s ' c e n t r a l a n d v o l u m e s o u r c e s o f c a r e b y c o n d u c t i n g a c o m m u n i t y s u r v e y o f h o u s e h o l d s i n t h e R o c h e s t e r , New Y o r k a r e a . H o w e v e r , t h e i r s t u d y i s n o t c o m p a t i b l e w i t h S o l o n a n d R i g g ' s f o r t w o r e a s o n s : (1) T h e s a m p l i n g f r a m e s d i f f e r b e t w e e n t h e t w o s t u d i e s . W h e r e a s S t r a t m a n n a n d U l l m a n c o n d u c t e d a h o u s e h o l d s u r v e y , S o l o n a n d R i g g 1 s s a m p l i n g 26 f r a m e was r e s t r i c t e d t o t h o s e i n d i v i d u a l s who a c t u a l l y v i s i t e d a n e m e r g e n c y d e p a r t m e n t . O f t h e t o t a l r e s p o n d e n t s i n S t r a t m a n n a n d U l l m a n . ' s s t u d y , o n l y 53 p e r c e n t h a d e v e r v i s i t e d a n e m e r g e n c y d e p a r t m e n t a t o n e t i m e o r a n o t h e r d u r i n g t h e i r l i f e t i m e a n d o n l y 18 p e r c e n t h a d b e e n t o a n e m e r g e n c y d e p a r t m e n t d u r i n g t h e p a s t y e a r . (2) T h e d e f i n i t i o n o f v o l u m e s o u r c e o f c a r e d i f f e r s b e t w e e n t h e t w o s t u d i e s . S t r a t m a n n a n d U l l m a n c a l c u l a t e d t h e v o l u m e s o u r c e o f c a r e f r o m r e p o r t e d u t i l i z a t i o n o f m e d i c a l f a c i l i t i e s f o r t h e t r e a t m e n t o f r o u t i n e m e d i c a l p r o b l e m s , w h i l e S o l o n a n d R i g g i n c l u d e d u t i l i z a t i o n o f m e d i c a l f a c i l i t i e s f o r t h e t r e a t m e n t o f b o t h r o u t i n e a n d a c u t e m e d i c a l p r o b l e m s . I n a d d i t i o n t o d e t e r m i n i n g t h e c e n t r a l a n d v o l u m e s o u r c e s o f c a r e , S t r a t m a n n a n d U l l m a n a s k e d t h e i r r e s p o n d e n t s t o i d e n t i f y t h e i r s u b s t i t u t e c e n t r a l s o u r c e , a s s u m i n g t h e t e m p o r a r y n o n -a v a i l a b i l i t y o f t h e i r p r i m a r y c e n t r a l s o u r c e . O n c e a g a i n , t h e r e s u l t s s h o w t h e p r e d o m i n a n c e o f p r i v a t e p h y s i c i a n s i n t h e r e s p o n -d e n t s ' p a t t e r n s o f m e d i c a l c a r e . A p r i v a t e d o c t o r w a s t h e v o l u m e s o u r c e o f c a r e f o r 68 p e r c e n t o f t h e r e s p o n d e n t s , w h e r e a s a n e m e r -g e n c y r o o m was t h e v o l u m e s o u r c e f o r o n l y 1 p e r c e n t . I n a d d i t i o n , 76 p e r c e n t o f t h e r e s p o n d e n t s m e n t i o n e d a p r i v a t e d o c t o r a s t h e i r p r i m a r y c e n t r a l s o u r c e o f c a r e , w h i l e o n l y 6 p e r c e n t m e n t i o n e d a n e m e r g e n c y r o o m . On t h e o t h e r h a n d , t h e m a j o r i t y o f t h e r e s p o n d e n t s ( 7 3 p e r c e n t ) i n d i c a t e d t h a t a n e m e r g e n c y r o o m was t h e i r s u b s t i t u t e c e n t r a l s o u r c e o f m e d i c a l c a r e . On t h e b a s i s o f t h e i r d a t a , S t r a t m a n n a n d U l l m a n c o n c l u d e d " w h i l e i t i s c l e a r t h a t f o r m o s t R o c h e s t e r r e s i d e n t s t h e ER [ e m e r g e n c y r o o m ] i s n e i t h e r a p r i m a r y 27 c e n t r a l o r volume s o u r c e o f c a r e , i t i s e v i d e n t t h a t h o s p i t a l ER's a r e i m p o r t a n t components o f t h e l o c a l m e d i c a l c a r e s y s t e m ( p . 1 0 3 7 ) . " In a p r e v i o u s s e c t i o n , r e s e a r c h f i n d i n g s were p r e s e n t e d w h i c h showed t h a t a l a r g e p r o p o r t i o n o f p a t i e n t s seek t r e a t m e n t a t emergency d e p a r t m e n t s f o r n o n - u r g e n t m e d i c a l p r o b l e m s . I t was s u g g e s t e d t h a t emergency d e p a r t m e n t s have become a major s o u r c e o f p r i m a r y m e d i c a l c a r e ( i . e . , f a m i l y o r g e n e r a l m e d i c i n e ) . D e s p i t e t h i s s u b s t a n t i a l amount o f n o n - u r g e n t u s a g e , however, s t u d i e s r e v i e w e d i n t h e p r e s e n t s e c t i o n i n d i c a t e t h a t o n l y a m i n o r i t y o f t h e p a t i e n t s p e r c e i v e t h e emergency d e p a r t m e n t t o be t h e i r p r i m a r y c e n t r a l s o u r c e o f c a r e and r e l a t i v e l y few p a t i e n t s u t i l i z e t h i s f a c i l i t y o f t e n enough f o r i t t o q u a l i f y as t h e i r u s u a l o r volume s o u r c e o f c a r e . One p o s s i b l e e x p l a n a t i o n t o a c c o u n t f o r t h e above f i n d i n g s i s t h a t a l a r g e number o f i n f r e -q u e n t u s e r s a r e t u r n i n g t o t h e emergency d e p a r t m e n t f o r t h e t r e a t -ment o f r o u t i n e p r o b l e m s when t h e i r p r i m a r y c e n t r a l o r volume s o u r c e o f c a r e i s n o t a v a i l a b l e . A l t h o u g h some u s e f u l i n f o r m a t i o n has been g a t h e r e d c o n c e r n i n g t h e r o l e o f t h e emergency d e p a r t m e n t i n t h e h e a l t h c a r e s y s t e m , most o f t h e s t u d i e s r e v i e w e d i n t h i s s e c t i o n must be c o n s i d e r e d e x p l o r a t o r y i n n a t u r e . W i t h t h e e x c e p t i o n o f two s t u d i e s ( S o l o n and R i g g , 1972; S t r a t m a n n and U l l m a n , 1975), i n v e s t i g a t o r s have f a i l e d t o c o n s i d e r t h e q u a l i t a t i v e i m p o r t a n c e t o i n d i v i d u a l s o f t h e v a r i o u s m e d i c a l c a r e f a c i l i t i e s . O t h e r m e t h o d o l o g i c a l d i f f i -c u l t i e s h i n d e r our u n d e r s t a n d i n g o f how t h e emergency d e p a r t m e n t 28 f i t s i n t o t h e p a t i e n t s ' o v e r a l l m e d i c a l c a r e p a t t e r n s . S i n c e t h e o b j e c t i v e s , t e c h n i q u e s , s a m p l i n g f r a m e s a n d d e f i n i t i o n s h a v e v a r i e d g r e a t l y f r o m s t u d y t o s t u d y , i t i s v e r y d i f f i c u l t t o c o m p a r e t h e d a t a o b t a i n e d i n o n e s t u d y w i t h t h a t o b t a i n e d i n a n o t h e r ( T o r r e n s a n d Y e d v a b , 1 9 7 0 ) . N e v e r t h e l e s s , on t h e b a s i s o f a v a i l a b l e r e s e a r c h d a t a , T o r r e n s a n d Y e d v a b ( 1 9 7 0 ) s u g g e s t t h a t t h e e m e r g e n c y d e p a r t m e n t p r e s e n t l y p e r f o r m s t h r e e g e n e r a l f u n c t i o n s : (1) t r a u m a - t r e a t m e n t c e n t r e w h i c h p r o v i d e s a c u t e e m e r g e n c y c a r e ; (2) s u b s t i t u t e f o r p r i v a t e p h y s i c i a n s a n d o u t p a t i e n t d e p a r t m e n t s when t h e s e s e r v i c e s a r e n o t a c c e s s i b l e t o p a t i e n t s ; a n d (3) " f a m i l y p h y s i c i a n " f o r i m p o v e r i s h e d u r b a n d w e l l e r s . I t s h o u l d be e m p h a s i z e d , h o w e v e r , t h a t e a c h h o s -p i t a l w i l l l i k e l y e x p e r i e n c e i t s own p e c u l i a r e m e r g e n c y d e p a r t m e n t u t i l i z a t i o n p a t t e r n s , w i t h d i f f e r e n t f u n c t i o n s p r e d o m i n a t i n g a t d i f f e r e n t h o s p i t a l s . F o r e x a m p l e , t h e r e l a t i v e i m p o r t a n c e o f t h e v a r i o u s f u n c t i o n s p e r f o r m e d b y e m e r g e n c y d e p a r t m e n t s may v a r y b e t w e e n C a n a d a a n d t h e U n i t e d S t a t e s , r e f l e c t i n g t h e l a c k o f n a t i o n a l h e a l t h i n s u r a n c e i n t h e l a t t e r c o u n t r y . O b v i o u s l y , m o r e r e s e a r c h i s r e q u i r e d b e f o r e o n e c a n f u l l y u n d e r s t a n d how t h e e m e r g e n c y d e p a r t m e n t f i t s i n t o t h e p a t i e n t s ' m e d i c a l c a r e p a t t e r n s . A s n o t e d b y S o l o n a n d R i g g ( 1 9 7 2 ) , "... t h e m o s t s u b t l e a n d e l u s i v e i d e n t i f i c a t i o n o f an e m e r g e n c y u n i t ' s p l a c e i n t h e s c h e m e o f t h i n g s i s t h e r e l a t i o n o f t h e u n i t ' s u s e t o o t h e r s o u r c e s f r o m w h i c h i t s c l i e n t e l e r e c e i v e m e d i c a l s e r -v i c e s ^ . 6 1 ) . " 29 C H A P T E R I I I R E S E A R C H D E S I G N The p r o j e c t was c o n d u c t e d i n t h e e m e r g e n c y d e p a r t m e n t o f L i o n s G a t e H o s p i t a l , a g e n e r a l p u b l i c h o s p i t a l l o c a t e d i n t h e C i t y o f N o r t h V a n c o u v e r , B r i t i s h C o l u m b i a . T h e s e r v i c e a r e a o f t h e h o s p i t a l i n c l u d e s t h e m u n i c i p a l i t i e s o f W e s t V a n c o u v e r , N o r t h V a n c o u v e r C i t y a n d N o r t h V a n c o u v e r D i s t r i c t ( t h e s e m u n i c i -p a l i t i e s a r e c o m m o n l y r e f e r r e d t o a s t h e N o r t h S h o r e ) . A t t h e t i m e o f t h e s t u d y , L i o n s G a t e H o s p i t a l h a d a c a p a c i t y o f 4 8 5 a c u t e c a r e b e d s a n d 1 7 0 e x t e n d e d c a r e b e d s . Th e n u m b e r o f v i s i t s t o i t s e m e r g e n c y d e p a r t m e n t h a s i n c r e a s e d s u b s t a n t i a l l y d u r i n g r e c e n t y e a r s . ( I t s h o u l d be n o t e d , h o w e v e r , t h a t L i o n s G a t e H o s p i t a l d o e s n o t h a v e a s e p a r a t e o u t p a t i e n t d e p a r t m e n t , w i t h t h e r e s u l t t h a t p a t i e n t s w i t h s c h e d u l e d a p p o i n t m e n t s a r e t r e a t e d i n t h e e m e r g e n c y d e p a r t m e n t . D u r i n g t h e s t u d y p e r i o d , 1 1 . 6 p e r c e n t o f t h e r e c o r d e d e m e r g e n c y d e p a r t m e n t v i s i t s w e r e s c h e d u l e d a p p o i n t m e n t s . ) I n 1 9 6 6 , t h e r e w e r e 2 1 , 7 8 9 p a t i e n t v i s i t s t o t h e e m e r g e n c y d e p a r t m e n t . T h i s f i g u r e h a d i n c r e a s e d t o 3 1 , 4 0 2 b y 1 9 7 1 , a n i n c r e a s e o f 4 4 . 1 p e r c e n t . D u r i n g t h e same t i m e p e r i o d , t h e p o p u l a t i o n o f t h e N o r t h S h o r e i n c r e a s e d b y o n l y 1 7 . 9 p e r c e n t . E m e r g e n c y d e p a r t m e n t v i s i t s h a v e c o n t i n u e d t o i n c r e a s e , w i t h 3 9 , 0 2 5 v i s i t s r e c o r d e d d u r i n g 1 9 7 4 ( a n i n c r e a s e o f 2 4 . 3 p e r c e n t s i n c e 1 9 7 1 ) . S a m p l e The s t u d y w a s c o n d u c t e d d u r i n g 14 d a y s i n S e p t e m b e r , 1 9 7 4 . T h e s a m p l i n g s c h e d u l e was d i v i d e d i n t o 1 2 - h o u r s e g m e n t s , c o v e r i n g 30 a l l h o u r s o f t h e d a y a n d a l l d a y s o f t h e w e e k . D u r i n g t h e w e e k o f S e p t e m b e r 13 - 1 9 , d a t a w e r e c o l l e c t e d f r o m N o o n t o 1 1 : 5 9 P.M.; d u r i n g t h e w e e k o f S e p t e m b e r 22 - 2 8 , d a t a w e r e c o l l e c t e d f r o m M i d n i g h t t o 1 1 : 5 9 A.M. An a t t e m p t was made t o c o l l e c t i n f o r m a t i o n f r o m a s many p a t i e n t s a s p o s s i b l e , w i t h t h e e x c e p t i o n o f p a t i e n t s w i t h s c h e d u l e d a p p o i n t m e n t s . T h e l a t t e r w e r e e x c l u d e d f r o m t h e s t u d y s i n c e t h e y a r e a c t u a l l y o u t p a t i e n t d e p a r t m e n t p a t i e n t s r a t h e r t h a n e m e r g e n c y d e p a r t m e n t p a t i e n t s . D a t a w e r e c o l l e c t e d b y p a t i e n t s , n o t b y v i s i t s . T h u s , p a t i e n t s who made r e p e a t v i s i t s t o t h e e m e r g e n c y d e p a r t m e n t d u r i n g t h e s t u d y p e r i o d w e r e a s k e d f o r i n f o r m a t i o n o n l y o n c e , s o t h a t h i g h - f r e q u e n c y u s e r s w o u l d n o t be o v e r r e p r e s e n t e d i n t h e s a m p l e . I n a c t u a l f a c t , o n l y t e n p a t i e n t s made r e p e a t v i s i t s d u r i n g t h e s a m p l i n g p e r i o d . D a t a C o l l e c t i o n D a t a w e r e g a t h e r e d b y q u e s t i o n n a i r e s a d m i n i s t e r e d i n t h e e m e r g e n c y d e p a r t m e n t . A s n o t e d b y W e i n e r m a n , R u t z e n a n d P e a r s o n ( 1 9 6 5 ) , t h e t e c h n i c a l p r o b l e m s r e l a t e d t o r e s e a r c h i n t h e e m e r g e n c y s e t t i n g a r e o f t e n f o r m i -d a b l e , a s m i g h t b e e x p e c t e d i n s u c h a h e c -t i c a n d c r i s i s - o r i e n t e d e n v i r o n m e n t ... P r o p e r s a m p l i n g t e c h n i q u e s r e q u i r e d a t a c o l l e c t i o n a t a l l h o u r s a n d d u r i n g a l l d a y s o f t h e w e e k . T i m e a v a i l a b l e f o r c o n -t a c t s w i t h p a t i e n t s a n d s t a f f i s l i m i t e d , a n d m o v e m e n t o f b o t h g r o u p s t o a n d f r o m v a r i o u s o t h e r h o s p i t a l d e p a r t m e n t s i s c o n -s t a n t (p . 397 ) . I n o r d e r t o m i n i m i z e t h e d e m a n d s p l a c e d o n t h e p a t i e n t s i n s u c h a " c r i s i s - o r i e n t e d " e n v i r o n m e n t , a q u e s t i o n n a i r e was d e v e l o p e d w h i c h c o n t a i n s c l o s e - e n d e d q u e s t i o n s ( s e e A p p e n d i x 4 ) . D u r i n g 31 A u g u s t 1 9 7 4 , t h e a u t h o r m e t w i t h t h e e m e r g e n c y d e p a r t m e n t s t a f f t o e x p l a i n t h e p r o j e c t t o t h e m . F o l l o w i n g t h e s e m e e t i n g s , t h e q u e s t i o n n a i r e was p r e t e s t e d , a n d a p p r o p r i a t e c h a n g e s w e r e made t o c l a r i f y c e r t a i n q u e s t i o n s . P a t i e n t s ( o r t h e p a t i e n t s ' e s c o r t s ) w e r e g i v e n t h e q u e s t i o n -n a i r e b y t h e a d m i t t i n g c l e r k s , a n d a s k e d t o a n s w e r t h e q u e s t i o n s w h i l e w a i t i n g t o r e c e i v e m e d i c a l t r e a t m e n t . To a c c o m m o d a t e t h o s e p a t i e n t s who p r e f e r r e d t o f i l l o u t t h e q u e s t i o n n a i r e a t home, a s e l f - a d d r e s s e d , s t a m p e d e n v e l o p e w a s p r o v i d e d . T h e a u t h o r was p r e s e n t a t a l l t i m e s d u r i n g t h e s a m p l i n g p e r i o d t o p r o v i d e a s s i s -t a n c e t o t h e p a t i e n t s , a n d t o c o l l e c t t h e c o m p l e t e d q u e s t i o n n a i r e s . L i m i t a t i o n s o f t h e S t u d y I n i t i a l l y , i t was p l a n n e d t o c o n d u c t t h e s t u d y a t s e v e r a l V a n c o u v e r a r e a h o s p i t a l s . ' H o w e v e r , d u e t o r e s t r i c t i o n s o f t i m e , f i n a n c e s a n d m a n p o w e r , d a t a w e r e c o l l e c t e d a t a s i n g l e e m e r g e n c y d e p a r t m e n t , a n d n o t a t o t h e r e m e r g e n c y d e p a r t m e n t s i n t h e V a n c o u v e r a r e a o r o t h e r f a c i l i t i e s i n t h e h e a l t h c a r e s y s t e m . O b v i o u s l y , a l l f a c i l i t i e s w i t h i n t h e h e a l t h c a r e s y s t e m a r e i n t e r r e l a t e d , a n d v a l u a b l e i n s i g h t s c a n b e o b t a i n e d f r o m an a n a l y s i s o f t h e e n t i r e s y s t e m . A s H a m i l t o n ( 1 9 7 4 ) o b s e r v e s , " ... i t i s c l e a r t h a t r a t i o n a l e m e r g e n c y c a r e p l a n n i n g c a n n o t b e c o n d u c t e d i n i s o l a t i o n f r o m p l a n n i n g f o r o t h e r h e a l t h s e r v i c e s ( p . 1 6 1 ) . " N o t w i t h s t a n d i n g t h e i m p o r t a n c e o f s y s t e m s a n a l y s i s , i t i s a l s o e v i d e n t t h a t i n s t i t u t i o n a l s t u d i e s o f t h e p r e s e n t t y p e c a n p r o v i d e i m p o r t a n t i n f o r m a t i o n f o r p l a n n i n g p u r p o s e s . A s n o t e d 32 i n a p r e v i o u s s e c t i o n , m o s t s o l u t i o n s w h i c h a r e p r o p o s e d t o r e s o l v e t h e " e m e r g e n c y d e p a r t m e n t c r i s i s " i g n o r e t h e i n d i v i d u -a l i t y o f e a c h h o s p i t a l ' s p a t t e r n s o f u t i l i z a t i o n , a n d a r e t o o g e n e r a l t o be o f v a l u e t o t h e h o s p i t a l ' s a d m i n i s t r a t o r s . E a c h h o s p i t a l h a s u n i q u e p r o b l e m s t h a t m u s t be e x a m i n e d i n a t t e m p t i n g t o a d j u s t t o t h e c h a n g i n g d e m a n d f o r e m e r g e n c y d e p a r t m e n t s e r -v i c e s . I n s t i t u t i o n a l s t u d i e s a r e n o t a s u b s t i t u t e f o r r e g i o n a l o r c o m m u n i t y - w i d e i n v e s t i g a t i o n s o f t h e e n t i r e h e a l t h c a r e s y s t e m , N o n e t h e l e s s , i n s t i t u t i o n a l s t u d i e s a r e u s e f u l i n d e t e r m i n i n g t h e u n i q u e r o l e w h i c h a p a r t i c u l a r f a c i l i t y f u l f i l l s i n i t s c o m m u n i t y (Wood, P r y b i l a n d S i m p s o n , 1 9 7 4 ) . One o b j e c t i v e o f t h e p r o j e c t i s t o e x a m i n e how t h e e m e r -g e n c y d e p a r t m e n t f i t s i n t o t h e p a t i e n t s ' o v e r a l l p a t t e r n s o f m e d i c a l c a r e . P a r t o f t h i s p r o c e s s i n v o l v e s d e t e r m i n i n g t h e p a t i e n t s ' u s a g e o f v a r i o u s a m b u l a t o r y m e d i c a l r e s o u r c e s a n d f a c i -l i t i e s d u r i n g a o n e - y e a r p e r i o d . T h e p a t i e n t s ' u t i l i z a t i o n p a t -t e r n s w e r e d e t e r m i n e d f r o m s e l f - r e p o r t e d u s a g e o f t h e v a r i o u s m e d i c a l s e r v i c e s . O b v i o u s l y , t h e r e l i a b i l i t y o f s e 1 f - r e p o r t e d u t i l i z a t i o n i s s u s p e c t , a l t h o u g h some e v i d e n c e d o e s e x i s t o f t h e g e n e r a l a c c u r a c y o f t h i s t y p e o f d a t a ( T o r r e n s a n d Y e d v a b , 1 9 7 0 ) . U n f o r t u n a t e l y , s i n c e t h e a u t h o r d i d n o t h a v e a c c e s s t o t h e m e d i c a l r e c o r d s o f t h e p a t i e n t s , i t was n o t p o s s i b l e t o v e r i f y t h e p a t i e n t - r e p o r t s o f p r i o r u t i l i z a t i o n . F i n a l l y , t h e r e l a t i v e l y s h o r t s a m p l i n g p e r i o d may l i m i t t h e g e n e r a l i t y o f t h e f i n d i n g s . I t i s r e c o g n i z e d t h a t some 33 u n c o n t r o l l e d f a c t o r s may i n f l u e n c e t h e u t i l i z a t i o n o f L i o n s G a t e ' s emergency d e p a r t m e n t . C o n s e q u e n t l y , p e r i o d i c d a t a c o l -l e c t i o n i s n e c e s s a r y t o o b t a i n a more c o m p r e h e n s i v e p i c t u r e o f t h e u t i l i z a t i o n o f t h i s f a c i l i t y . 34 CHAPTER IV DATA ANALYSIS Q u e s t i o n n a i r e s were d i s t r i b u t e d t o 493 p a t i e n t s d u r i n g t h e s a m p l i n g p e r i o d , 422 (85.60 p e r c e n t ) o f whom r e s p o n d e d . Not a l l p a t i e n t s , however, were i n c l u d e d i n t h e sample. As n o t e d e a r l i e r , p a t i e n t s w i t h s c h e d u l e d a p p o i n t m e n t s were e x c l u d e d f r o m t h e s t u d y . R e g a r d i n g t h o s e w i t h o u t s c h e d u l e d a p p o i n t m e n t s , t h e most p r o m i n e n t r e a s o n f o r o m i t t i n g c e r t a i n p a t i e n t s was due t o t h e h e c t i c n a t u r e o f t h e emergency d e p a r t m e n t d u r i n g busy h o u r s -some p a t i e n t s were s i m p l y " l o s t " d u r i n g busy t i m e p e r i o d s . In a d d i t i o n , a s m a l l number o f s e r i o u s l y i l l o r i n j u r e d p a t i e n t s were e x c l u d e d from t h e s t u d y on t h e a d v i c e o f t h e a d m i t t i n g c l e r k s . A few p a t i e n t s , due t o su c h f a c t o r s as d r u g o r a l c o h o l a b u s e , were j u d g e d t o be i n c a p a b l e o f p r o v i d i n g a c c u r a t e i n f o r -m a t i o n . F i n a l l y , some p a t i e n t s r e f u s e d t o c o m p l e t e t h e q u e s t i o n -n a i r e , a l t h o u g h such o c c u r r e n c e s were v e r y i n f r e q u e n t . D a t a were co d e d , and a n a l y z e d t h r o u g h t h e use o f t h e MVTAB ( M u l t i v a r i a t e C o n t i n g e n c y T a b u l a t i o n s ) computer p r o g r a m . F r e -quency and p e r c e n t a g e d i s t r i b u t i o n s were d e r i v e d f o r d e s c r i p t i v e p u r p o s e s . R e g a r d i n g t h e c o m p u t a t i o n o f p e r c e n t a g e s , t h e base f o r p e r c e n t a g i n g was a l w a y s t a k e n as t h o s e who r e s p o n d e d t o a p a r t i c u l a r q u e s t i o n , n o t t h e t o t a l sample o f 422. C r o s s t a b u l a -t i o n s and t e s t s o f s i g n i f i c a n c e by c h i - s q u a r e were p e r f o r m e d f o r a n a l y t i c p u r p o s e s , w i t h a p r o b a b i l i t y o f l e s s t h a n 0.05 a c c e p t e d as s i g n i f i c a n t . 35 P a t i e n t s ' C u r r e n t V i s i t t o t h e Emergency D e p a r t m e n t The f i r s t o b j e c t i v e o f t h e p r o j e c t was t o u n d e r s t a n d why p a t i e n t s seek t r e a t m e n t a t t h e emergency d e p a r t m e n t o f L i o n s Gate H o s p i t a l . T h i s phase o f t h e p r o j e c t b r i n g s t o g e t h e r a v a r i e t y o f d a t a r e l a t e d t o t h e p a t i e n t s ' c u r r e n t v i s i t t o t h e emergency d e p a r t m e n t . Emergency d e p a r t m e n t s have t r a d i t i o n a l l y been a s s o c i a t e d w i t h t h e t r e a t m e n t o f t h e s e r i o u s l y i l l and i n j u r e d . As p r e -v i o u s l y m e n t i o n e d , however, numerous s t u d i e s c o n f i r m t h a t a l a r g e p r o p o r t i o n of t h e p o p u l a t i o n now p e r c e i v e s t h e emergency d e p a r t m e n t t o be an a p p r o p r i a t e s o u r c e o f p r i m a r y m e d i c a l c a r e . O b v i o u s l y , t h e n a t u r e o f t h e demand f o r emergency s e r v i c e s i s an i m p o r t a n t f a c t o r i n t h e w o r k l o a d o f the emergency d e p a r t m e n t , and a p p r o p r i a t e o r g a n i z a t i o n a l and s t a f f i n g a r r a n g e m e n t s depend upon the e x t e n t t o w h i c h t h e d e p a r t m e n t i s p r o v i d i n g c r i s i s c a r e as opposed t o p r i m a r y m e d i c a l c a r e . T h e r e f o r e , i n p l a n n i n g f o r f u t u r e change o f an emergency d e p a r t m e n t , i t i s i m p o r t a n t t o a s s e s s t h e p a t i e n t mix o f t h e d e p a r t m e n t i n terms o f t h e n a t u r e , d u r a t i o n and s e v e r i t y o f p a t i e n t s ' m e d i c a l c o m p l a i n t s . I t has been w e l l documented i n the h e a l t h c a r e l i t e r a t u r e t h a t , a c c o r d i n g t o m e d i c a l p e r s o n n e l , a s u b s t a n t i a l p r o p o r t i o n of emergency d e p a r t m e n t p a t i e n t s s eek t r e a t m e n t f o r n o n u r g e n t m e d i c a l p r o b l e m s ( i . e . , t h e d i s o r d e r does n o t r e q u i r e t h e r e s o u r -c e s o f an emergency d e p a r t m e n t ) . I t i s o b v i o u s , however, t h a t t h e r e may be d i f f e r e n c e s between p h y s i c i a n s ' and p a t i e n t s ' p e r c e p t i o n s o f t h e s e v e r i t y of m e d i c a l c o m p l a i n t s . C o n s e q u e n t l y , 36 i t i s o f i n t e r e s t t o know whether p a t i e n t s t h e m s e l v e s p e r c e i v e t h e i r c o n d i t i o n s t o be n o n u r g e n t . T h i s i n f o r m a t i o n i s i m p o r t a n t as i t f o c u s e s on t h e e x t e n t t o w h i c h t h e emergency d e p a r t m e n t i s s u b s t i t u t i n g f o r o t h e r components o f t h e a m b u l a t o r y h e a l t h c a r e s y s t e m . The d a t a s u g g e s t t h a t L i o n s G a t e ' s emergency d e p a r t m e n t i s i n d e e d s u b s t i t u t i n g f o r t h e w i d e r p r i m a r y c a r e s y s t e m . —" F o r t y p e r c e n t o f t h e p a t i e n t s s t a t e d t h a t t h e i r i n j u r y o r i l l n e s s was n o n u r g e n t ( T a b l e 5 ) . r* • " ' " ~ '•' f • vTABLE 5 DISTRIBUTION OF PATIENTS BY PATIENTS' ASSESSMENT OF THE URGENCY OF THEIR PRESENTING COMPLAINT PATIENTS' ASSESSMENT PATIENTS OF URGENCY NUMBER PERCENTAGE S e v e r e 85 20 . 73 U r g e n t 161 39 . 27 N o n u r g e n t 164 40 . 00 T o t a l 410 100% The i n c r e a s i n g t e n d e n c y o f p a t i e n t s t o u t i l i z e t h e emer-gency d e p a r t m e n t f o r n o n u r g e n t c o n d i t i o n s i s o f major c o n c e r n t o h o s p i t a l a d m i n i s t r a t o r s . In o r d e r t o p r o v i d e f u r t h e r i n s i g h t i n t o t h i s phenomenon, c r o s s t a b u l a t i o n s between p a t i e n t - r e p o r t e d u r g e n c y o f c o m p l a i n t s and v a r i o u s o t h e r v i s i t c h a r a c t e r i s t i c s were p e r f o r m e d . These r e l a t i o n s h i p s w i l l be d i s c u s s e d i n s u b s e -q u e n t s e c t i o n s o f t h e r e p o r t . F o r t h e p u r p o s e o f t h e s e a n a l y s i s , _1. As s u b s e q u e n t d a t a w i l l i l l u s t r a t e , t h e p r o b l e m r e l a t e s t o t h e a c c e s s i b i l i t y o f g e n e r a l p r a c t i t i o n e r s r a t h e r t h a n t o a s h o r t a g e o f d o c t o r s i n t h e community. The N o r t h S h o r e , w i t h a p p r o x i m a t e l y one g e n e r a l p r a c t i t i o n e r p e r t h o u s a n d o f popu-l a t i o n , has more g e n e r a l p r a c t i t i o n e r s t h a n t h e g u i d e l i n e e s t a b l i s h e d by t h e R o y a l C o l l e g e o f P h y s i c i a n s and S u r g e o n s (one g e n e r a l p r a c t i t i o n e r p e r 1500 p o p u l a t i o n ) . 37 s e v e r e c o n d i t i o n s w e r e c o m b i n e d w i t h , a n d w i l l b e r e f e r r e d t o a s , u r g e n t c o n d i t i o n s t o p r o v i d e a c o n t r a s t w i t h n o n u r g e n t c o n d i t i o n s , s i n c e o n l y t h e l a t t e r a r e c o m m o n l y c o n s i d e r e d b y h e a l t h c a r e p e r s o n n e l t o b e i n a p p r o p r i a t e f o r e m e r g e n c y d e p a r t m e n t c a r e . T a b l e '.6 s h o w s t h e p r o p o r t i o n o f p a t i e n t s w i t h t r a u m a t i c a n d n o n t r a u m a t i c c o n d i t i o n s . T h r e e - f o u r t h s o f t h e s a m p l e d p a t i e n t s c a m e , t o L i o n s G a t e f o r t h e t r e a t m e n t o f a n i n j u r y , w h e r e a s o n l y o n e - f o u r t h s o u g h t t r e a t m e n t f o r a n i l l n e s s . T A B L E 6 D I S T R I B U T I O N O F P A T I E N T S B Y N A T U R E O F P R E S E N T I N G C O M P L A I N T P A T I E N T S N A T U R E O F C O M P L A I N T I n j u r y I l i n e s s N U M B E R 314 106 P E R C E N T A G E 74.76 25.24 T o t a l 420 100% P a t i e n t s w e r e a l s o a s k e d t o i n d i c a t e h o w l o n g t h e i r i n j u r y o r i l l n e s s h a d b e e n p r e s e n t b e f o r e t h e i r v i s i t t o t h e e m e r g e n c y d e p a r t m e n t ( T a b l e 7 ) . I n t o t a l , h a l f o f t h e s a m p l e d p a t i e n t s s p e c i f i e d t h a t t h e o n s e t o f t h e i r c o m p l a i n t h a d b e e n w i t h i n t w o h o u r s , w i t h 38.41 p e r c e n t r e p o r t i n g a d u r a t i o n o f l e s s t h a n o n e h o u r . F o u r - f i f t h s o f t h e p a t i e n t s c a m e t o t h e e m e r g e n c y d e p a r t -m e n t w i t h i n 24 h o u r s o f t h e o n s e t o f t h e i r m e d i c a l c o n d i t i o n . A s o u t l i n e d i n T a b l e 8 , p a t i e n t s s u f f e r i n g f r o m a n i n j u r y a r e 38 much more l i k e l y t h a n t h o s e s u f f e r i n g f r o m an i l l n e s s t o come th e emergency d e p a r t m e n t w i t h i n 24 h o u r s o f t h e o n s e t o f t h e i r d i s o r d e r ( s i g n i f i c a n t a t t h e .001 l e v e l ) . The d u r a t i o n o f com p l a i n t c a t e g o r i e s i n T a b l e 8, were c o l l a p s e d i n t o "24 h o u r s o r l e s s " and "more t h a n 24 h o u r s " on the a s s u m p t i o n t h a t a t i m e p e r i o d o f g r e a t e r t h a n 24 h o u r s u s u a l l y a f f o r d s p a t i e n t s t h e o p p o r t u n i t y t o c o n t a c t a p h y s i c i a n . TABLE 7 PERCENTAGE DISTRIBUTION OF PATIENTS BY NATURE AND DURATION OF PRESENTING COMPLAINT DURATION OF COMPLAINT L e s s Than 1 Hour 1 - 2 Hours 3 - 1 2 Hours 13 - 24 Hours 2 - 7 Days More Than 7 Days NATURE OF COMPLAINT T o t a l P e r c e n t a g e Number INJURY 48 . 08 12 .82 16.99 11 .86 7.37 2 .88 100% 312 ILLNESS 8 .82 10.78 17 . 65 13.73 28 .43 20.59 100% 102 TOTAL 38 .41 12 . 32 17.15 12.32 12.56 7.25 100% 414 TABLE 8 PERCENTAGE DISTRIBUTION OF PATIENTS WITHIN EACH NATURE OF COMPLAINT CATEGORY BY DURATION OF COMPLAINT  DURATION NATURE OF COMPLAINT IOE/ COMPLAINT INJURY ILLNESS TOTAL 24 Hours o r L e s s 89.74 50.98 80.19 More Than 24 Hours 10.26 49.02 19.81 T o t a l P e r c e n t a g e 100% 100% 100% Number 312 102 414 39 A n a l y s i s a l s o d i s c l o s e d a s i g n i f i c a n t r e l a t i o n s h i p ( a t the .05 l e v e l o f c o n f i d e n c e ) between the d u r a t i o n o f c o m p l a i n t s on t h e one hand, and p a t i e n t - r e p o r t e d u r g e n c y o f c o m p l a i n t s on t h e o t h e r . Not s u r p r i s i n g l y , s i g n i f i c a n t l y l e s s use o f t h e emer-gency d e p a r t m e n t f o r n o n u r g e n t c o n d i t i o n s was made by p a t i e n t s who came t o t h i s f a c i l i t y w i t h i n 24 h o u r s o f t h e o n s e t o f t h e i r m e d i c a l d i s o r d e r . Y e t , even f o r t h i s g r o u p o f p a t i e n t s , o v e r a t h i r d p e r c e i v e d t h e i r d i s o r d e r t o be n o n u r g e n t ( T a b l e 9 ) . TABLE § PERCENTAGE DISTRIBUTION OF PATIENTS WITHIN EACH DURATION OF COMPLAINT CATEGORY BY PATIENTS' ASSESSMENT OF URGENCY DURATION PATIENTS' ASSESSMENT OF URGENCY OF COMPLAINT NUMBER TOTAL URGENT NONURGENT 24 Hours o r L e s s 324 100% 62 . 65 37.35 Moire Than 24 Hours 82 100% 48.78 51.22 T o t a l 406 100% 59.85 40 .15 A somewhat s u r p r i s i n g f i n d i n g i s t h e l a c k o f a s i g n i f i c a n t r e l a t i o n s h i p between the n a t u r e o f c o m p l a i n t and p a t i e n t - r e p o r t e d u r g e n c y o f c o n d i t i o n . I t was e x p e c t e d t h a t i n j u r i e s would be more l i k e l y t h a n i l l n e s s e s t o be p e r c e i v e d as b e i n g u r g e n t and r e q u i r i n g a c u t e m e d i c a l a t t e n t i o n . In a c t u a l f a c t , i l l n e s s e s were more l i k e l y t h a n i n j u r i e s t o be r a t e d as u r g e n t (65.69 p e r -c e n t compared t o 58.17 p e r c e n t ) , a l t h o u g h t h e d i f f e r e n c e i s n o t s i g n i f i c a n t . 40 Some i n s i g h t i n t o p a t i e n t s 1 m o t i v e s f o r s e e k i n g c a r e a t an emergency d e p a r t m e n t i s d e r i v e d f r o m d a t a on r e f e r r a l s o u r c e s . As o u t l i n e d i n T a b l e 10, 223 p a t i e n t s were s e l f - r e f e r r a l s ; o f t h i s g r o u p , 163 p a t i e n t s d e c i d e d t h e m s e l v e s t o come d i r e c t l y t o the emergency d e p a r t m e n t and 60 r e l i e d s o l e l y on t h e a d v i c e o f f r i e n d s , r e l a t i v e s or n e i g h b o u r s . Thus, o v e r h a l f o f t h e sampled p a t i e n t s came d i r e c t l y t o t h e h o s p i t a l w i t h o u t a d v i c e f r o m m e d i c a l p e r s o n n e l o r r e s p o n s i b l e l a y g r o u p s ( p o l i c e , e m p l o y e r s , t e a c h e r s and t h e l i k e ) . On the o t h e r hand, a t h i r d o f t h e p a t i e n t s were r e f e r r e d to the emergency d e p a r t m e n t by p r i v a t e p h y s i c i a n s . A s u r p r i s i n g f i n d i n g was t h e l a c k o f s i g n i f i c a n t d i f f e r e n c e s i n p a t i e n t - r e p o r t e d u r g e n c y r a t i n g s among p a t i e n t s r e f e r r e d by d i f f e r e n t s o u r c e s . Most s u r p r i s i n g i s t h e f a c t t h a t p a t i e n t s r e f e r r e d by p r i v a t e p h y s i c i a n s a r e as l i k e l y as o t h e r s t o use the emergency d e p a r t m e n t f o r n o n u r g e n t c o n d i t i o n s . TABLE 1"0 DISTRIBUTION OF PATIENTS BY SOURCE OF REFERRAL TO THE EMERGENCY DEPARTMENT PATIENTS REFERRAL SOURCE S e l f R e f e r r a l P r i v a t e P h y s i c i a n O u t p a t i e n t D e p a r t m e n t Ambulance or P o l i c e E m p l o y e r or T e a c h e r O t h e r S o u r c e s NUMBER 223 138 3 6 31 17 PERCENTAGE 53.35 33 . 01 0.72 1 .44 7 .42 4 . 07 T o t a l 418 100% 41 Whereas T a b l e 1.0 r e l a t e s t o p a t i e n t s ' m o t i v e s i n s e e k i n g t r e a t m e n t a t an emergency d e p a r t m e n t as o p p o s e d t o a l t e r n a t i v e a m b u l a t o r y m e d i c a l f a c i l i t i e s , T a b l e 11 r e f e r s t o p a t i e n t s ' m o t i v e s i n c h o o s i n g a p a r t i c u l a r emergency d e p a r t m e n t o v e r o t h e r s . TABLE .'11 DISTRIBUTION OF PATIENTS BY REASONS FOR SEEKING TREATMENT AT LIONS GATE'S EMERGENCY DEPARTMENT REASONS FOR CHOOSING LIONS GATE  C l o s e s t Emergency Department C l o s e s t + R e p u t a t i o n o f H o s p i t a l C l o s e s t + P r i o r T r e a t m e n t C l o s e s t + D i r e c t R e f e r r a l R e p u t a t i o n o f H o s p i t a l P r i o r T r e a t m e n t D i r e c t R e f e r r a l P r i o r T r e a t m e n t + D i r e c t R e f e r r a l O t h e r Reasons T o t a l PATIENTS NUMBER 227 7 16 29 8 34 63 14 24 422 PERCENTAGE 53.79 1 . 66 3.79 6.87 1 . 90 8 . 06 14.93 3 .32 5 . 69 100% L i o n s Gate H o s p i t a l i s t h e ' o n l y h o s p i t a l on t h e N o r t h S h o r e . C o n s e q u e n t l y , i t i s n o t s u r p r i s i n g t h a t t w o - t h i r d s o f t h e p a t i e n t s c i t e d l o c a t i o n as a f a c t o r i n t h e i r s e l e c t i o n o f L i o n s G a t e ' s emergency d e p a r t m e n t . More t h a n h a l f o f t h e p a t i e n t s came t o t h i s f a c i l i t y b e c a u s e i t i s t h e c l o s e s t emergency d e p a r t m e n t , w h i l e a n o t h e r 12.32 p e r c e n t m e n t i o n e d l o c a t i o n i n c o n j u n c t i o n w i t h a n o t h e r r e a s o n ( i . e . , t h e g e n e r a l r e p u t a t i o n o f L i o n s G ate, p r i o r 42 t r e a t m e n t a t L i o n s G a t e , or d i r e c t r e f e r r a l t o t h e emergency d e p a r t m e n t ) . I t i s o f i n t e r e s t t o n o t e t h a t t h e p r e d o m i n a n c e o f l o c a -t i o n as a f a c t o r i n t h e s e l e c t i o n o f L i o n s G a t e ' s emergency d e p a r t m e n t i s n o t due t o a l a c k o f i n d e p e n d e n t m o b i l i t y on t h e p a r t o f t h e p a t i e n t p o p u l a t i o n . The v a s t m a j o r i t y of t h e p a t i e n t s (85.75 p e r c e n t ) came t o t h e emergency d e p a r t m e n t by p r i v a t e c a r , w h i l e o n l y 3.56 p e r c e n t w a l k e d t o t h e h o s p i t a l and o n l y 1.19 p e r c e n t came by b u s . Of the r e m a i n d e r , a l l b u t one p a t i e n t came by e i t h e r t a x i , ambulance or p o l i c e v e h i c l e . As n o t e d i n t h e l i t e r a t u r e r e v i e w , t h e i n c r e a s e i n demand f o r emergency d e p a r t m e n t s e r v i c e s has been a t t r i b u t e d t o a v a r i e t y o f f a c t o r s . A l t h o u g h t h e r e l a t i v e i m p o r t a n c e o f t h e f a c t o r s has not been e s t a b l i s h e d , s e v e r a l s t u d i e s were c i t e d w h i c h s u g g e s t t h a t p r i v a t e p h y s i c i a n s a r e key f i g u r e s i n emergency d e p a r t m e n t u t i l i z a t i o n . The p h y s i c i a n s ' r e l a t i v e c o n t r i b u t i o n t o t h e usage o f emergency d e p a r t m e n t s depends upon s e v e r a l v a r i a b l e s , i n c l u d i n g t h e amount o f p h y s i c i a n r e f e r r a l , a c t u a l p h y s i c i a n n o n - a v a i l a b i l i t y and p e r c e i v e d p h y s i c i a n n o n - a v a i l a b i l i t y . M o r e o v e r , some a u t h o r s i n c l u d e p a t i e n t s ' l a c k of a f a m i l y d o c t o r . A r e v i e w o f a v a i l a b l e r e s e a r c h suggests- t h a t t h e e x t e n t t o w h i c h p r i v a t e p h y s i c i a n s c o n -t r i b u t e t o t h e demand f o r emergency d e p a r t m e n t t r e a t m e n t w i l l l i k e l y v a r y from h o s p i t a l t o h o s p i t a l . 43 T h e p r e s e n t p r o j e c t w a s d e s i g n e d t o h e l p d e t e r m i n e w h y p a t i e n t s s e e k t r e a t m e n t a t L i o n s G a t e ' s e m e r g e n c y d e p a r t m e n t ; a n d , p a r t i c u l a r l y , t o a s c e r t a i n w h e t h e r p h y s i c i a n s a r e t h e p r e -d o m i n a n t f a c t o r . I n t h i s r e g a r d , t h e s a m p l e d p a t i e n t s w e r e a s k e d t o i n d i c a t e w h e t h e r t h e y a t t e m p t e d t o c o n t a c t a p h y s i c i a n b e f o r e c o m i n g t o t h e e m e r g e n c y d e p a r t m e n t : T h i s d i s t i n c t i o n i s i m p o r t a n t i n d e t e r -m i n i n g w h o m a d e t h e d e c i s i o n t o u s e t h e e m e r g e n c y r o o m . W h e n a p a t i e n t s p e a k s t o h i s d o c t o r o n t h e t e l e p h o n e , h e m a y n o t b e c o n s i d e r i n g g o i n g t o t h e h o s p i t a l . W h e t h e r t h a t p a t i e n t u l t i m a t e l y g o e s t o t h e e m e r g e n c y r o o m d e p e n d s o n w h a t a c t i o n t h e p h y s i c i a n t a k e s . I f t h e p h y s i c i a n i n s t r u c t s t h e p a t i e n t t o g o t o t h e e m e r g e n c y r o o m , o b v i o u s l y t h e d o c t o r m a d e t h e d e c i s i o n t o u s e t h a t f a c i l i t y ( V a u g h a n & G a m e s t e r , 1966 ( a ) , p . 4 5 ) . T a b l e T 2 r e v e a l s t h a t a p p r o x i m a t e l y 60 p e r c e n t o f t h e p a t i e n t s c a m e d i r e c t l y t o t h e e m e r g e n c y d e p a r t m e n t w i t h o u t f i r s t a t t e m p t i n g t o c o n t a c t a p h y s i c i a n . T A B L E 12 D I S T R I B U T I O N O F P A T I E N T S B Y A T T E M P T T O C O N T A C T A P H Y S I C I A N B E F O R E E M E R G E N C Y D E P A R T M E N T V I S I T A T T E M P T E D T O C O N T A C T ' P H Y S I C I A N P A T I E N T S N U M B E R P E R C E N T A G E Y e s N o 159 259 38.04 61 . 96 T o t a l 418 100% 44 S i g n i f i c a n t d i f f e r e n c e s were f o u n d between b o t h t h e n a t u r e and t h e d u r a t i o n o f p r e s e n t i n g c o m p l a i n t s on t h e one hand, and p a t i e n t - a t t e m p t s to c o n t a c t a p h y s i c i a n on t h e o t h e r . As shown i n T a b l e 13, however, t h e n a t u r e o f c o m p l a i n t i s c l e a r l y t h e more i n f l u e n t i a l f a c t o r i n t h i s a s s o c i a t i o n . When n a t u r e and d u r a t i o n o f c o m p l a i n t a r e combined, t h e d a t a r e v e a l t h a t p a t i e n t s w i t h " r e c e n t " i n j u r i e s a r e most l i k e l y t o go d i r e c t l y t o t h e emergency d e p a r t m e n t , f o l l o w e d by p a t i e n t s w i t h " o l d " i n j u r i e s ( s i g n i f i c a n t a t t h e .001 l e v e l ) . TABLE 13 PERCENTAGE DISTRIBUTION OF PATIENTS WITHIN EACH NATURE AND . DURATION OF COMPLAINT CATEGORY BY ATTEMPT TO CONTACT A PHYSICIAN BEFORE EMERGENCY DEPARTMENT V I S I T NATURE AND DURATION ATTEMPTED TO CONTACT A PHYSICIAN OF COMPLAINT NUMBER TOTAL YES NO I n j u r y , 24 Hours or L e s s 227 100% 29.24 70 . 76 I n j u r y , More Than 24 Hours 32 100% 40.63 59 . 38 I l l n e s s , 24 Hours o r L e s s 52 100% 59.62 40 . 38 I l l n e s s , More Than 24 Hours 50 100% 62 . 00 38 . 00 T o t a l 411 100% 37.96 62 . 04 O r i g i n a l l y , emergency d e p a r t m e n t s were d e s i g n e d t o p r o v i d e a c u t e c a r e f o r the s e r i o u s l y i l l and i n j u r e d The c h a n g i n g r o l e of t h i s f a c i l i t y i s made e v i d e n t by t h e f a c t t h a t 40 p e r c e n t o f t h e ^ s a m p l e d p a t i e n t s p e r c e i v e d t h e i r d i s o r d e r t o be n o n u r g e n t . The p u b l i c ' s c h a n g i n g a t t i t u d e t oward t h e emergency d e p a r t m e n t i s f u r t h e r h i g h l i g h t e d by t h e f i n d i n g t h a t no s i g n i f i c a n t d i f f e r e n c e s e x i s t between u r g e n t and n o n u r g e n t p a t i e n t s r e g a r d i n g p a t i e n t -a t t e m p t s t o c o n t a c t a p h y s i c i a n . A c c o r d i n g t o t h e t r a d i t i o n a l 45 r o l e o f t h e emergency d e p a r t m e n t , one would e x p e c t u r g e n t p a t i e n t s t o be more l i k e l y t h a n n o n u r g e n t p a t i e n t s t o go d i r e c t l y t o t h e h o s p i t a l . In a c t u a l f a c t , however, a l a r g e r p r o p o r t i o n o f p a t i e n t s w i t h n o n u r g e n t c o n d i t i o n s went d i r e c t l y t o t h e emergency d e p a r t m e n t w i t h o u t a t t e m p t i n g t o c o n t a c t a d o c t o r , a l t h o u g h t h e d i f f e r e n c e i s n o t s t a t i s t i c a l l y s i g n i f i c a n t ( T a b l e 15) . TABLE 1:4 PERCENTAGE DISTRIBUTION OF PATIENTS WITHIN EACH SEVERITY OF COMPLAINT CATEGORY BY ATTEMPT TO CONTACT A PHYSICIAN BEFORE EMERGENCY DEPARTMENT V I S I T PATIENTS' ASSESSMENT OF URGENCY  U r g e n t N o n u r g e n t T o t a l ATTEMPTED TO CONTACT A PHYSICIAN  NUMBER TOTAL YES NO 245 100% 39.59 60.41 162 100% 33.95 66.05 407 100% 37.35 62.65 A l m o s t 40 p e r c e n t o f the sampled p a t i e n t s a t t e m p t e d t o c o n -t a c t a p h y s i c i a n b e f o r e coming t o t h e emergency d e p a r t m e n t ( T a b l e 12) . A d d i t i o n a l i n q u i r i e s were made t o d e t e r m i n e whether t h e s e p a t i e n t s were s u c c e s s f u l i n t h i s a t t e m p t , and a l s o t o d e t e r m i n e why t h e r e m a i n d e r o f t h e p a t i e n t s d i d n o t seek t r e a t m e n t or a d v i c e from a d o c t o r b e f o r e coming t o t h e h o s p i t a l . Most p a t i e n t s who a t t e m p t e d t o c o n t a c t a p h y s i c i a n were s u c c e s s f u l ( T a b l e 15) . E a r l i e r , d a t a on r e f e r r a l s o u r c e s ( T a b l e 10) d i s c l o s e d t h a t a t h i r d o f t h e p a t i e n t s were r e f e r r e d t o the emergency d e p a r t m e n t by a p r i v a t e p h y s i c i a n . These p h y s i c i a n r e f e r r a l s a r e r e p r e s e n t e d by Groups 1 and 2 i n T a b l e 15-46 P a t i e n t s i n Group 3 came to t h e emergency d e p a r t m e n t b e c a u s e o f a c t u a l p h y s i c i a n n o n - a v a i l a b i l i t y ; t h e s e p a t i e n t s t r i e d b u t f a i l e d t o c o n t a c t a d o c t o r . P e r c e i v e d p h y s i c i a n n o n - a v a i l a b i l i t y emerged as t h e most common r e a s o n why p a t i e n t s d i d n o t a t t e m p t t o c o n t a c t a d o c t o r ; 21.21 p e r c e n t o f t h e sampled p a t i e n t s came d i r e c t l y t o t h e h o s p i t a l a t l e a s t p a r t l y due t o t h e b e l i e f t h a t a p h y s i c i a n was not a v a i l a b l e . Over t h r e e - f o u r t h s o f t h i s l a t t e r g r o u p o f p a t i e n t s r e f e r r e d s o l e l y t o p e r c e i v e d p h y s i c i a n n o n - a v a i l a b i l i t y (Group 5 ) , w h i l e the r e m a i n d e r m e n t i o n e d t h i s r e a s o n i n c o n j u n c -t i o n w i t h a n o t h e r (Groups 6 and 7 ) . Two o t h e r r e a s o n s were men-t i o n e d by more t h a n t e n p e r c e n t o f t h e t o t a l number o f p a t i e n t s ; some find i t e a s i e r o r more c o n v e n i e n t t o go t o t h e emergency d e p a r t m e n t t h a n t o a d o c t o r ' s o f f i c e (Group 9 ) , w h i l e o t h e r s f e l t t h a t i mmediate c a r e or h o s p i t a l f a c i l i t i e s were r e q u i r e d (Group 1 0 ) . In t o t a l , 57.59 p e r c e n t o f t h e sampled p a t i e n t s came t o the emergency d e p a r t m e n t t h r o u g h e i t h e r d i r e c t or i n d i r e c t i n f l u e n c e by p r i v a t e p h y s i c i a n s (Groups 1 t h r o u g h 3, and Groups 5 t h r o u g h 7 ) . These p a t i e n t r e s p o n s e s i n d i c a t e t h a t p r i v a t e p h y s i c i a n s and t h e i r n o n - a v a i l a b i l i t y a r e t h e p r e d o m i n a n t f a c t o r s c o n t r i b u t i n g t o emergency d e p a r t m e n t usage a t L i o n s Gate H o s p i t a l . 47 TABLE 15 DISTRIBUTION OF PATIENTS BY PATIENTS' REASONS FOR CURRENT EMERGENCY DEPARTMENT V I S I T PHYSICIAN CALLED BEFORE V I S I T TO EMERGENCY DEPARTMENT PATIENTS NUMBER (157) PERCENTAGE (37 .83! 1. P h y s i c i a n T o l d P a t i e n t t o Go'- t o H o s p i t a l 2. P h y s i c i a n T o l d P a t i e n t t o Meet Him a t H o s p i t a l 3. P a t i e n t t r i e d b u t F a i l e d t o C o n t a c t P h y s i c i a n 4. O t h e r 73 65 13 6 17 .59 15 . 66 3.13 1.45 PHYSICIAN NOT CALLED BEFORE V I S I T TO EMERGENCY DEPARTMENT (258) (62.17) 5. P a t i e n t F e l t P h y s i c i a n Not A v a i l a b l e 69 6. P a t i e n t F e l t P h y s i c i a n Not A v a i l a b l e + Emergency De p a r t m e n t i s More C o n v e n i e n t 10 7. P a t i e n t F e l t P h y s i c i a n Not A v a i l a b l e + Immediate or H o s p i t a l C a r e R e q u i r e d 9 8. No F a m i l y P h y s i c i a n 22 9. Emergency D e p a r t m e n t i s More C o n v e n i e n t 47 10. Immediate or H o s p i t a l C a r e R e q u i r e d 46 16 . 63 2 .41 2 .17 5.30 11 .33 11 . 08 11. P a t i e n t S e n t by E m p l o y e r , Ambulance, e t c . 12 O t h e r Reasons 24 31 5 .78 7 .47 T o t a l 415 100% 48 As e a r l i e r m e n t i o n e d , some a u t h o r s i n c l u d e t h e l a c k o f a f a m i l y d o c t o r as p a r t o f t h e p h y s i c i a n s ' r e l a t i v e c o n t r i b u t i o n t o emergency d e p a r t m e n t u t i l i z a t i o n , b a s e d on t h e a s s u m p t i o n t h a t t h e l a c k o f a f a m i l y d o c t o r r e p r e s e n t s a n o t h e r component o f p h y s i c i a n n o n - a v a i l a b i l i t y . W h i l e t h i s a s s u m p t i o n may be v a l i d f o r some a r e a s , l a c k o f a f a m i l y d o c t o r among o u r sample o f p a t i e n t s i s m a i n l y due to t h e g e o g r a p h i c a l m o b i l i t y o f p a t i e n t s r a t h e r t h a n a s h o r t a g e o f d o c t o r s i n t h e community. C o n s e q u e n t l y , p a t i e n t s who s t a t e d t h a t t h e y came d i r e c t l y t o t h e h o s p i t a l b e c a u s e t h e y have no f a m i l y d o c t o r (Group a r e n o t c o n s i d e r e d t o r e f l e c t t h e e x t e n t t o w h i c h p r i v a t e p h y s i c i a n s c o n t r i b u t e t o the demand f o r emergency d e p a r t m e n t s e r v i c e s . I t i s i n t e r e s t i n g t o n o t e , however, t h a t one o t h e r r e a s o n does r e l a t e somewhat t o p h y s i c i a n n o n - a v a i l a b i l i t y . E l e v e n p e r -c e n t o f t h e p a t i e n t s came d i r e c t l y t o t h e emergency d e p a r t m e n t b e c a u s e t h e y f e e l t h a t t h i s f a c i l i t y i s more c o n v e n i e n t than- a d o c t o r ' s o f f i c e (Group 9 ) . These p a t i e n t r e s p o n s e s r e l a t e t o th e r e l a t i v e a c c e s s i b i l i t y o f emergency d e p a r t m e n t s and p r i v a t e p h y s i c i a n s , and s h o u l d p e r h a p s be c o n s i d e r e d as r e f l e c t i n g a n o t h e r component o f p h y s i c i a n n o n - a v a i l a b i l i t y . I f t h i s i n t e r -p r e t a t i o n i s c o r r e c t , t h e n 68.92 p e r c e n t o f t h e p a t i e n t s came to t h e h o s p i t a l t h r o u g h d i r e c t or i n d i r e c t i n f l u e n c e o f p r i v a t e p h y s i c i a n s . R e g a r d l e s s o f whether p a t i e n t s i n Group 9 a r e c o n -s i d e r e d t o r e p r e s e n t a n o t h e r component o f p h y s i c i a n non-a v a i l a b i l i t y , i t i s c l e a r t h a t t h e p r e s e n t s t u d y s u p p o r t s t h e c o n c l u s i o n r e a c h e d by Vaughan and Gamester (1966 a ; 1966 ;b) t h a t p h y s i c i a n s a r e key f i g u r e s i n emergency d e p a r t m e n t u t i l i -z a t i o n . 49 P a t i e n t s ' O v e r a l l P a t t e r n s o f M e d i c a l C a r e The s e c o n d o b j e c t i v e o f t h e p r o j e c t was t o d e t e r m i n e t h e r e l a t i o n o f t h e emergency d e p a r t m e n t t o i t s p a t i e n t s ' o t h e r s o u r c e s o f a m b u l a t o r y m e d i c a l c a r e . As e m p h a s i z e d by S o l o n , Sheps and Lee ( 1 9 6 0 ( b ) , "... a p e r s o n ' s use o f a p a r t i c u l a r m e d i c a l r e s o u r c e - be i t p r i v a t e p r a c t i t i o n e r , o u t p a t i e n t c l i n i c , o r o t h e r s o u r c e o f m e d i c a l s e r v i c e s - t a k e s on g r e a t e r meaning when examined from t h e p e r s p e c t i v e o f t h e whole r a n g e o f m e d i c a l c a r e r e s o u r c e s w h i c h he u s e s ( p . 1 9 0 5 ) . " I t i s l i k e l y t h a t L i o n s G a t e ' s emergency d e p a r t m e n t p e r -forms m u l t i p l e r o l e s among t h e p a t i e n t s i t s e r v e s . F o r some, t h e emergency d e p a r t m e n t w i l l p r o v i d e t o t a l o r n e a r - t o t a l c a r e , w h i l e f o r o t h e r s i t w i l l p r o v i d e o n l y a p a r t i c u l a r segment o f c a r e . To t h u s i d e n t i f y v a r i o u s t y p e s o f u s e r s i s t o i m p l y t h a t d i v e r g e n t m e d i c a l c a r e r o l e s , w i t h d i f f e r e n t i a l r e s p o n s i b i l i t i e s , a r e i n d i c a t e d f o r t h e emergency d e p a r t m e n t . What i s r e q u i r e d o f the emergency d e p a r t m e n t , i f o p t i m a l c a r e i s t o be p r o v i d e d , i s r e s p o n s i v e n e s s t o t h e v a r i a t i o n s o f need w h i c h i t s p a t i e n t s e x h i b i t . A l t e r n a t i v e l y , i f i t i s r e s o l v e d t h a t p a t i e n t s a r e f o l l o w i n g i n a p p r o p r i a t e p a t t e r n s o f c a r e , e f f o r t s c a n be d i r e c t e d t o w a r d a l t e r i n g t h e p a t t e r n s o f t h o s e j u d g e d t o be m i s u s i n g t h e emergency d e p a r t m e n t . These c h a l l e n g e s can be met, however, o n l y i f t h e emergency d e p a r t m e n t i s v i e w e d i n terms o f how i t f i t s i n t o t h e o v e r a l l m e d i c a l c a r e p a t t e r n s o f i t s p a t i e n t s ( S o l o n , 1966; S o l o n , Sheps & Lee, 1 9 6 6 ( b ) . 50 T h i s phase o f t h e p r o j e c t i n v o l v e d c o l l e c t i n g i n f o r m a t i o n n o t o n l y a b o u t t h e p a t i e n t s ' usage o f t h e emergency d e p a r t m e n t , b u t a b o u t t h e i r use o f a m b u l a t o r y m e d i c a l s e r v i c e s i n g e n e r a l . F i r s t , t o i d e n t i f y t h e s u b s e t o f p a t i e n t s f o r whom t h e emergency d e p a r t m e n t may be s e r v i n g as t h e " f a m i l y p h y s i c i a n , " t h e p a t i e n t s were a s k e d whether t h e y have a f a m i l y d o c t o r . As shown i n T a b l e 16, a p p r o x i m a t e l y 90 p e r c e n t o f t h e p a t i e n t s s t a t e d t h a t t h e y do have a f a m i l y d o c t o r ; t h e m a j o r i t y o f p a t i e n t s who do n o t i n d i -c a t e d t h a t a r e c e n t move to a new g e o g r a p h i c a l l o c a t i o n (by them-s e l v e s o r , i n a s m a l l number of c a s e s , by t h e i r f o r m e r d o c t o r ) i s t h e r e a s o n f o r t h e i r l a c k o f a f a m i l y p h y s i c i a n . O n l y 3 p a t i e n t s s t a t e d t h a t t h e y do n o t have a f a m i l y d o c t o r b e c a u s e t h e y p r e f e r t o use an emergency d e p a r t m e n t f o r m e d i c a l c a r e ( T a b l e I 7 ) . A d m i t t e d l y , t h e i n f o r m a t i o n i n T a b l e 16 does n o t t e l l t h e c o m p l e t e s t o r y o f t h e p a t i e n t s ' r e l a t i o n s h i p w i t h a f a m i l y d o c t o r . F o r i n s t a n c e , more and more d o c t o r s a r e l i k e l y t o be s p e c i a l i s t s r a t h e r t h a n g e n e r a l p r a c t i t i o n e r s : Some o f t h e s e p a t i e n t s may n o t know a g e n e r a l p r a c t i t i o n e r a t a l l . They may have r e p o r t e d t h a t t h e y have a f a m i l y p h y s i c i a n i f some member o f th e f a m i l y i s or has been under t h e c a r e o f a s p e c i a l i s t s u c h as a p e d i a t r i c i a n or o b s t e -t r i c i a n . The i l l n e s s w h i c h o c c a s i o n e d t h i s v i s i t t o t h e h o s p i t a l may have been o u t s i d e t h e scope o f p r a c t i c e o f t h e s p e c i a l i s t s t h e y know (Vaughan & Gamester, 1 9 6 6 ( a ) , pp. 46 & 4 7 ) . D e s p i t e t h e above m e n t i o n e d l i m i t a t i o n , i t seems r e a s o n a b l e t o assume t h a t t h e emergency d e p a r t m e n t s e r v e s as t h e " f a m i l y 51 p h y s i c i a n " f o r v e r y few o f t h e sampled p a t i e n t s . O n l y t e n p e r -c e n t o f t h e p a t i e n t s do h o t have a f a m i l y d o c t o r ; o f t h e s e , most s t a t e d t h a t t h e i r r e l a t i o n s h i p w i t h a f a m i l y d o c t o r has been i n t e r u p t e d by a r e c e n t move t o a new g e o g r a p h i c a l l o c a t i o n . TABLE i f r DISTRIBUTION OF PATIENTS BY PATIENTS' RELATIONSHIP WITH A FAMILY DOCTOR  PATIENT HAS A PATIENTS FAMILY DOCTOR NUMBER PERCENTAGE Yes 375 89.29 No 45 10.71 T o t a l 420 100% TABLE 17-DISTRIBUTION OF PATIENTS BY PATIENTS' REASONS FOR NOT HAVING A FAMILY DOCTOR*'  PATIENTS PATIENTS' REASONS NUMBER PERCENTAGE R e c e n t l y Moved 28 63.64 Not Needed i n P a s t 4 9.09 P r e f e r Emergency D e p a r t m e n t 3 6.82 P r e f e r O u t p a t i e n t D e p a r t m e n t 1 2.27 O t h e r Reasons 8 18.18 T o t a l 44 100% The sampled p a t i e n t s were a l s o a s k e d t o s p e c i f y t h e number of t i m e s t h e y have r e c e i v e d m e d i c a l t r e a t m e n t d u r i n g t h e p r e v i o u s 12 months ( i n c l u d i n g t h e i r c u r r e n t v i s i t t o t h e emergency d e p a r t -m ent), and t o i n d i c a t e t h e m e d i c a l s o u r c e s f r o m w h i c h t h e t r e a t -ment was o b t a i n e d . A o n e - y e a r t i m e p e r i o d was s e l e c t e d t o e n s u r e 52 a l o n g enough p e r i o d o f t i m e t o r e f l e c t p a t i e n t s ' u s u a l methods o f o b t a i n i n g m e d i c a l c a r e , b u t n o t too l o n g as t o e x c e e d a r e a s o n a b l y a c c u r a t e memory sp a n . The d i f f e r e n t s o u r c e s , and d i f f e r e n t c o m b i n a t i o n o f s o u r c e s , o f a m b u l a t o r y c a r e w h i c h t h e p a t i e n t s u t i l i z e i s one i n d i c a t i o n o f t h e e x t e n t t o w h i c h t h e y r e l y on t h e emergency d e p a r t m e n t t o meet t h e i r m e d i c a l c a r e n e e d s . The d a t a r e v e a l t h a t t h e m a j o r i t y o f t h e p a t i e n t s r e c e i v e d m e d i c a l t r e a t m e n t d u r i n g t h e p r i o r y e a r f r o m b o t h a p r i v a t e p h y s i c i a n and an emergency d e p a r t m e n t . On the o t h e r hand, a s u b s t a n t i a l p r o p o r t i o n o f t h e p a t i e n t s ( o v e r a t h i r d ) r e l i e d s o l e l y on t h e emergency d e p a r t m e n t f o r t h e i r m e d i c a l c a r e . R e l a t i v e l y few p a t i e n t s r e c e i v e d t r e a t m e n t f r om an o u t -p a t i e n t d e p a r t m e n t , r e f l e c t i n g t h e a b s e n c e o f t h i s t y p e o f f a c i l i t y a t L i o n s Gate H o s p i t a l ( T a b l e 1*8) . TABLE 18V DISTRIBUTION OF PATIENTS ACCORDING TO SOURCES OF AMBULATORY CARE USED DURING THE PAST YEAR SOURCES OF AMBULATORY CARE Emergency D e p a r t m e n t O n l y E. D. + P r i v a t e P h y s i c i a n E . D . + 0 . P . D . E. D. + P r i v a t e P h y s i c i a n + 0 . P . D . PATIENTS NUMBER 139 239 2 11 PERCENTAGE 35.55 61 .13 0.51 2 . 81 T o t a l 391 100% 53 F r e q u e n c y o f use o f t h e emergency d e p a r t m e n t i s a n o t h e r i n d i c a t i o n o f t h e e x t e n t t o w h i c h p a t i e n t s r e l y on t h i s f a c i l i t y f o r t h e i r m e d i c a l c a r e . Most p a t i e n t s a r e i n f r e q u e n t u s e r s o f t h e emergency d e p a r t m e n t - t h e i r c u r r e n t v i s i t r e p r e s e n t s t h e i r o n l y v i s i t t o t h i s f a c i l i t y d u r i n g t h e p a s t 12 months ( T a b l e 1 9 ) . N o n e t h e l e s s , a s u b s t a n t i a l number (36.90 p e r c e n t ) made m u l t i p l e v i s i t s t o t h e emergency d e p a r t m e n t . M o r e o v e r , 56 p a t i e n t s (14.25 p e r c e n t ) may be termed f r e q u e n t or r e g u l a r u s e r s , h a v i n g made t h r e e o r more emergency d e p a r t m e n t v i s i t s d u r i n g t h e p a s t y e a r . I t i s o f i n t e r e s t t o n o t e t h a t t h e v a s t m a j o r i t y o f t h e p a t i e n t s (90.58 p e r c e n t ) r e c e i v e d a l l o f t h e i r emergency d e p a r t -ment t r e a t m e n t a t L i o n s Gate H o s p i t a l . TABLE 19 DISTRIBUTION OF PATIENTS BY NUMBER OF EMERGENCY DEPARTMENT V I S I T S DURING THE PAST YEAR AND BY HOSPITAL SITE NUMBER OF V I S I T S , BY HOSPITAL PATIENTS NUMBER PERCENTAGE One V i s i t , L i o n s Gate 248 63.10 Two V i s i t s , L i o n s Gate 66 16.79 Two V i s i t s , L i o n s Gate + O t h e r H o s p i t a l 23 5 .85 T h r e e o r More V i s i t s , L i o n s Gate 42 10 . 69 T h r e e o r More V i s i t s , L i o n s Gate + O t h e r H o s p i t a l (s) 14 3 . 56 T o t a l 393 100% 54 A l t h o u g h i d e n t i f y i n g t h e p a t i e n t s ' v a r i o u s s o u r c e s o f a m b u l a t o r y c a r e , as w e l l as d o c u m e n t i n g t h e i r f r e q u e n c y o f use o f t h e emergency d e p a r t m e n t , p r o v i d e s some u s e f u l i n s i g h t s i n t o t h e i r m e d i c a l c a r e p a t t e r n s , some i n t e g r a t i n g p e r s p e c t i v e i s r e q u i r e d t o c l e a r l y u n d e r s t a n d t h e s t r u c t u r e o f t h e s e p a t t e r n s . T h i s i n t e g r a t i n g p e r s p e c t i v e i s a c h i e v e d p r i m a r i l y t h r o u g h t h e c o n c e p t s o f volume and c e n t r a l s o u r c e o f c a r e , e a c h o f w h i c h p i n p o i n t s a p i v o t a l s o u r c e i n t h e p a t i e n t s ' p a t t e r n s o f c a r e ( S o l o n & R i g g , 1 9 72). The volume s o u r c e o f c a r e i s t h e m e d i c a l r e s o u r c e o r f a c i l i t y w h i c h was most o f t e n u t i l i z e d d u r i n g t h e p r e v i o u s 12 months, i n c l u d i n g t h e p a t i e n t s ' c u r r e n t emergency d e p a r t m e n t v i s i t . P r i v a t e p h y s i c i a n s r e p r e s e n t t h e volume s o u r c e o f c a r e f o r t h e l a r g e s t g r o u p o f p a t i e n t s ( T a b l e 2 0 ) . However, a l m o s t as l a r g e a g r o u p u t i l i z e d t h e emergency d e p a r t m e n t as t h e i r volume s o u r c e . S i x t y p a t i e n t s (15.35 p e r c e n t ) p a t t e r n e d t h e i r m e d i c a l c a r e i n s u c h a way t h a t no m e d i c a l r e s o u r c e o r f a c i l i t y emerged as t h e i r volume s o u r c e . In a l m o s t a l l o f t h e s e l a t t e r c a s e s , t h e p a t i e n t s made e q u a l use o f an emergency d e p a r t m e n t and a p r i v a t e p h y s i c i a n . T h u s , o v e r h a l f o f t h e sampled p a t i e n t s u s e d th e emergency d e p a r t m e n t more o f t e n t h a n , or as o f t e n a s , o t h e r s o u r c e s o f a m b u l a t o r y c a r e . 55 TABLE 2 0 DISTRIBUTION OF PATIENTS BY VOLUME SOURCE OF CARE PATIENTS VOLUME SOURCE NUMBER PERCENTAGE Emergency Department 156 39.90 P r i v a t e P h y s i c i a n 172 43 .99 H o s p i t a l O u t p a t i e n t D e p a r t m e n t 3 0.77 No Volume S o u r c e 60 15.35 T o t a l 391 100% In a d d i t i o n t o i n d i c a t i n g t h e number o f t i m e s t h e y have r e c e i v e d t r e a t m e n t from v a r i o u s m e d i c a l s o u r c e s d u r i n g t h e p r e v i o u s y e a r , t h e p a t i e n t s s p e c i f i e d t h e i r c e n t r a l s o u r c e o f c a r e . T h i s c o n c e p t i s i m p o r t a n t i n a s s e s s i n g t h e q u a l i t a t i v e i m p o r t a n c e i o f t h e v a r i o u s s o u r c e s o f m e d i c a l c a r e . As d e s c r i b e d by S o l o n and R i g g (1972), The i n d i v i d u a l ' s c e n t r a l s o u r c e o f c a r e i s h i s f o c a l m e d i c a l r e s o u r c e - n o t n e c e s -s a r i l y i n p o i n t o f t i m e , s e q u e n c e , o r volume o f u s e , b u t i n i t s b e i n g t o him t h e most i m p o r t a n t f a c i l i t y o r p h y s i c i a n to whom he t u r n s when he needs m e d i c a l a d v i c e o r c a r e . I t i s t h e most i m p o r t a n t t o him i n t h e s e n s e o f h i s h a v i n g h i s g r e a t e s t c o n t i n u i n g t r u s t o r r e l i a n c e i n t h a t s o u r c e ( p . 6 3 ) . As o u t l i n e d i n T a b l e 21, t h e emergency d e p a r t m e n t i s t h e most i m p o r t a n t m e d i c a l r e s o u r c e f o r n i n e p e r c e n t o f t h e p a t i e n t s , w h i l e an a d d i t i o n a l s i x p e r c e n t c e n t r a l i z e t h e i r c a r e a r o u n d b o t h t h e emergency d e p a r t m e n t and a p r i v a t e p h y s i c i a n . F o r t h e v a s t 56 m a j o r i t y o f t h e p a t i e n t s , h o w e v e r , c a r e i s c e n t r a l i z e d a r o u n d a p r i v a t e p h y s i c i a n . A s m a l l n u m b e r o f p a t i e n t s do n o t p a t t e r n t h e i r c a r e a r o u n d a c e n t r a l s o u r c e ; t h e s e p a t i e n t s i n d i c a t e d t h a t t h e y h a v e no p r e f e r e n c e among t h e v a r i o u s m e d i c a l s o u r c e s . T A B L E SI-D I S T R I B U T I O N OF P A T I E N T S BY C E N T R A L SOURCE OF CARE P A T I E N T S C E N T R A L SOURCE NUMBER P E R C E N T A G E E m e r g e n c y D e p a r t m e n t 38 9.18 P r i v a t e P h y s i c i a n 342 8 2 . 6 1 H o s p i t a l O u t p a t i e n t D e p a r t m e n t 0 -E. D. + P r i v a t e P h y s i c i a n 24 5.80 No C e n t r a l S o u r c e 10 2.42 T o t a l 4 1 4 1 0 0 % G r e a t e r i n s i g h t i n t o t h e p a t i e n t s ' o v e r a l l p a t t e r n s o f m e d i c a l c a r e c a n be a c h i e v e d b y c o m p a r i n g t h e p a t i e n t s ' c e n t r a l a n d v o l u m e s o u r c e s o f c a r e ( T a b l e s 2'2 & 23) . T h i s a n a l y s i s a l l o w s u s t o i d e n t i f y t h o s e p a t i e n t s who r e l y m o s t h e a v i l y o n t h e e m e r g e n c y d e p a r t m e n t t o s a t i s f y t h e i r m e d i c a l c a r e n e e d s . A s o u t l i n e d i n T a b l e 2 3 , t h e e m e r g e n c y d e p a r t m e n t o c c u p i e s t h e p r e d o m i n a n t p o s i t i o n i n t h e m e d i c a l c a r e p a t t e r n s o f a p p r o x i -m a t e l y e i g h t p e r c e n t o f t h e p a t i e n t s ; o f t h i s g r o u p , 5.70 p e r c e n t u s e t h e e m e r g e n c y d e p a r t m e n t f o r b o t h c e n t r a l i z i n g a n d v o l u m e p u r p o s e s a n d 2 . 5 9 p e r c e n t c e n t r a l i z e t h e i r c a r e a r o u n d b o t h t h e e m e r g e n c y d e p a r t m e n t a n d a p r i v a t e p h y s i c i a n a n d a l s o u t i l i z e t h e e m e r g e n c y d e p a r t m e n t a s t h e i r v o l u m e s o u r c e o f c a r e . 57 The most f r e q u e n t p a t t e r n o f c a r e a p p e a r i n g among t h e sampled p a t i e n t s i s t h e use o f a p r i v a t e p h y s i c i a n f o r b o t h c e n t r a l and volume p u r p o s e s (39.12 p e r c e n t o f p a t i e n t s ) . On the o t h e r hand, a l m o s t a t h i r d o f t h e p a t i e n t s (30.31 p e r c e n t ) c e n t r a l i z e t h e i r c a r e a r o u n d a p r i v a t e p h y s i c i a n b u t u t i l i z e t h e emergency d e p a r t m e n t as t h e i r volume s o u r c e o f c a r e . T h i s l a t t e r f i n d i n g i n d i c a t e s , e s p e c i a l l y when c o n s i d e r e d i n c o n j u n c t i o n w i t h p r e v i o u s l y r e p o r t e d d a t a r e g a r d i n g p a t i e n t s ' r e a s o n s f o r t h e i r c u r r e n t emergency d e p a r t m e n t v i s i t , t h a t numerous p a t i e n t s t u r n t o t h e emergency d e p a r t m e n t due t o t h e n o n - a v a i l a b i l i t y o f p r i v a t e p h y s i c i a n s . TABLE 2 2 FREQUENCY DISTRIBUTION OF PATIENTS BY CENTRAL AND VOLUME SOURCES OF CARE CENTRAL SOURCE OF CARE E.D. + NO VOLUME SOURCE PRIVATE PRIVATE CENTRAL OF CARE E.D. PHYSICIAN PHYSICIAN SOURCE TOTAL Emergency D e p a r t m e n t 22 117 10 2 151 P r i v a t e P h y s i c i a n 10 151 7 4 172 H o s p i t a l O u t p a t i e n t D e p a r t m e n t 0 2 0 1 3 No Volume S o u r c e 1 52 5 2 60 T o t a l 33 322 22 9 386 58 TABLE 2.3 PERCENTAGE DISTRIBUTION OF PATIENTS BY CENTRAL AND VOLUME SOURCES OF CARE CENTRAL SOURCE OF CARE VOLUME SOURCE OF CARE E.D, PRIVATE PHYSICIAN E.D. + PRIVATE PHYSICIAN NO CENTRAL SOURCE TOTAL Emergene y De p a r t m e n t Pr i v a t e P h y s i c i a n H o s p i t a l O u t p a t i e n t D e p a r t m e n t No Volume Sou r c e 5.70 2 .59 0. 26 30.31 39.12 0 . 52 13.47 2.59 1 .81 1.30 0 . 52 1 . 04 0.26 0 . 52 39.12 44.56 0 . 78 15.54 T o t a l 8 . 55 83.42 5.70 2.33 100% F u r t h e r a n a l y s i s r e v e a l s a s t r o n g a s s o c i a t i o n between p a t i e n t s ' c e n t r a l and volume s o u r c e s o f c a r e . T a b l e 24 s e p a r a t e s p a t i e n t s who c e n t r a l i z e t h e i r c a r e s o l e l y a r o u n d t h e emergency d e p a r t m e n t from t h o s e who c e n t r a l i z e t h e i r c a r e e l s e w h e r e . L i k e w i s e , p a t i e n t s a r e g r o u p e d a c c o r d i n g t o whether o r n o t t h e y u t i l i z e t h e emergency d e p a r t m e n t as t h e i r volume s o u r c e o f c a r e . Not s u r p r i s i n g l y , t h e d a t a show t h a t p a t i e n t s who use t h e emergency d e p a r t m e n t as t h e i r c e n t r a l s o u r c e o f c a r e a r e much more l i k e l y t h a n o t h e r s t o a l s o u t i l i z e t h i s f a c i l i t y as t h e i r volume s o u r c e o f c a r e ( s i g n i f i c a n t a t t h e .001 l e v e l ) . 59 TABLE 2 4-PERCENTAGE DISTRIBUTION OF PATIENTS WITHIN EACH CENTRAL SOURCE OF CARE CATEGORY BY VOLUME SOURCE OF CARE  CENTRAL SOURCE OF CARE VOLUME SOURCE OF CARE Emergency D e p a r t m e n t O t h e r S o u r c e s * * T o t a l EMERGENCY DEPARTMENT 66 .67 33 .33 P e r c e n t a g e 100% Number 33 OTHER SOURCES* 36 . 54 63 .46 100% 353 TOTAL 39.12 60 . 88 100% 386 * I n c l u d e s p a t i e n t s w i t h no c e n t r a l s o u r c e . ** I n c l u d e s p a t i e n t s w i t h no volume s o u r c e . What was s u r p r i s i n g , however, was t h e l a c k o f s i g n i f i c a n t d i f f e r e n c e s i n p a t i e n t - r e p o r t e d u r g e n c y o f c o m p l a i n t s among p a t i e n t s w i t h d i f f e r e n t p a t t e r n s o f o b t a i n i n g m e d i c a l c a r e . A n a l y s e s d i s c l o s e d t h a t n o n u r g e n t usage o f t h e emergency d e p a r t -ment i s n o t s i g n i f i c a n t l y r e l a t e d t o whether o r n o t p a t i e n t s (1) have a f a m i l y d o c t o r ; (2) made o n l y one o r more t h a n one v i s i t t o t h e emergency d e p a r t m e n t d u r i n g t h e p a s t 12 months; (3) use t h e emergency d e p a r t m e n t as t h e i r volume s o u r c e o f c a r e as o p p o s e d t o o t h e r s o u r c e s —*; (4) use a p r i v a t e p h y s i c i a n f o r volume p u r p o s e s as opp o s e d t o o t h e r s o u r c e s —; ; (5) c e n t r a l i z e t h e i r c a r e s o l e l y a r o u n d t h e emergency d e p a r t m e n t as oppo s e d t o 2 e l s e w h e r e —"; o r (6) use a p r i v a t e p h y s i c i a n f o r c e n t r a l i z i n g 2 . p u r p o s e s as opp o s e d t o o t h e r s o u r c e s — . R e g a r d l e s s o f t h e _1. I n c l u d e s p a t i e n t s w i t h no volume s o u r c e o f c a r e . 2, I n c l u d e s p a t i e n t s w i t h no c e n t r a l s o u r c e o f c a r e 60 above m e n t i o n e d v a r i a t i o n s i n t h e p a t i e n t s ' m e d i c a l c a r e p a t t e r n s , t h e r e a r e no s i g n i f i c a n t d i f f e r e n c e s i n t h e p r o p o r -t i o n o f p a t i e n t s who u t i l i z e t h e emergency d e p a r t m e n t f o r n o n u r g e n t c o n d i t i o n s . T hese f i n d i n g s s u g g e s t t h a t t h e emergency d e p a r t m e n t has g a i n e d wide a c c e p t a n c e by many segments o f t h e p o p u l a t i o n as a s o u r c e o f p r i m a r y m e d i c a l c a r e . 61 I CHAPTER V CONCLUSION Summary o f F i n d i n g s The u t i l i z a t i o n o f t h e emergency d e p a r t m e n t o f L i o n s Gate H o s p i t a l i s b e t t e r u n d e r s t o o d , h a v i n g been s t u d i e d b o t h i n r e l a -t i o n t o t h e p a t i e n t s ' c u r r e n t v i s i t t o t h i s f a c i l i t y and i n r e l a -t i o n t o t h e p a t i e n t s ' o t h e r s o u r c e s o f a m b u l a t o r y m e d i c a l c a r e . The f i n d i n g s o f t h e s t u d y i n d i c a t e t h a t p r i v a t e p h y s i c i a n s o c c u p y a p r e d o m i n a n t p l a c e i n t h e m e d i c a l c a r e p a t t e r n s o f t h e sampled p a t i e n t s . T h i s p r e d o m i n a n c e i s h i g h l i g h t e d by t h e f a c t t h a t (1) 82.61 p e r c e n t o f t h e p a t i e n t s c e n t r a l i z e t h e i r c a r e a r o u n d a p r i v a t e p h y s i c i a n ; (2) the l a r g e s t g r o u p o f p a t i e n t s (43.99 p e r c e n t ) u t i l i z e p r i v a t e p h y s i c i a n s f o r volume p u r p o s e s ; and (3) t h e most f r e q u e n t p a t t e r n o f c a r e a p p e a r i n g among t h e sampled p a t i e n t s i s t h e use o f a p r i v a t e p h y s i c i a n f o r b o t h c e n t r a l and volume p u r p o s e s (39.12 p e r c e n t o f t h e p a t i e n t s ) . N o n e t h e l e s s , t h e p r e d o m i n a n c e o f p r i v a t e p h y s i c i a n s s h o u l d n o t be a l l o w e d t o o b s c u r e t h e f a c t t h a t t h e emergency d e p a r t m e n t i t s e l f o c c u p i e s an i m p o r t a n t p l a c e i n t h e p a t i e n t s ' m e d i c a l c a r e p a t t e r n s , I n d e e d , i t o c c u p i e s t h e p r e d o m i n a n t p l a c e i n t h e p a t t e r n s o f a s m a l l , b u t n o t i n s u b s t a n t i a l , number o f t h e sampled p a t i e n t s . The i m p o r t a n c e o f t h e emergency d e p a r t m e n t 62 i s made e v i d e n t b y n u m e r o u s f i n d i n g s : (1) o v e r a t h i r d ( 3 5 . 5 5 p e r c e n t ) o f t h e p a t i e n t s r e c e i v e d a l l o f t h e i r a m b u l a t o r y m e d i -c a l c a r e d u r i n g t h e p r e v i o u s y e a r i n a n e m e r g e n c y d e p a r t m e n t ; (2) o v e r a t h i r d ( 3 6 . 9 0 p e r c e n t ) o f t h e p a t i e n t s made m u l t i p l e e m e r g e n c y d e p a r t m e n t v i s i t s d u r i n g t h e p r e v i o u s 12 m o n t h s ; (3) t h e e m e r g e n c y d e p a r t m e n t s e r v e s a s t h e v o l u m e s o u r c e o f c a r e f o r 3 9 . 9 0 p e r c e n t o f t h e p a t i e n t s ; (4) t h e e m e r g e n c y d e p a r t m e n t , e i t h e r s o l e l y o r i n c o n j u n c t i o n w i t h a p r i v a t e p h y s i c i a n , i s t h e c e n t r a l s o u r c e o f c a r e f o r 1 4 . 9 8 p e r c e n t o f t h e p a t i e n t s ; a n d (5) 8.29 p e r c e n t o f t h e p a t i e n t s u s e t h e e m e r g e n c y d e p a r t m e n t , e i t h e r s o l e l y o r i n c o n j u n c t i o n w i t h a p r i v a t e p h y s i c i a n , f o r c e n t r a l i z i n g p u r p o s e s a n d a l s o u t i l i z e t h e e m e r g e n c y d e p a r t m e n t a s t h e i r v o l u m e s o u r c e o f c a r e . T h e i m p o r t a n c e o f t h e e m e r g e n c y d e p a r t m e n t i n t h e p a t i e n t s ' o v e r a l l p a t t e r n s o f c a r e a p p e a r s t o b e d u e t o i t s a c c e s s i b i l i t y , e s p e c i a l l y i n c o m p a r i s o n t o p r i v a t e p h y s i c i a n s . P r i v a t e p h y s i -c i a n s a n d t h e i r n o n - a v a i l a b i l i t y w e r e f o u n d t o be t h e p r e d o m i n a n t f a c t o r s c o n t r i b u t i n g t o e m e r g e n c y d e p a r t m e n t u s a g e a t L i o n s G a t e H o s p i t a l . D a t a r e l a t e d t o t h e p a t i e n t s ' o v e r a l l p a t t e r n s o f m e d i c a l c a r e s h o w t h a t a l m o s t a t h i r d ( 3 0 . 3 1 p e r c e n t ) o f t h e p a t i e n t s c e n t r a l i z e t h e i r c a r e a r o u n d a p r i v a t e p h y s i c i a n b u t u t i l i z e t h e e m e r g e n c y d e p a r t m e n t a s t h e i r v o l u m e s o u r c e o f c a r e . T h i s l a t t e r f i n d i n g p r o v i d e s f u r t h e r e v i d e n c e t h a t n u m e r o u s p a t i e n t s t u r n t o t h e e m e r g e n c y d e p a r t m e n t d u e t o t h e n o n -a v a i l a b i l i t y o f p r i v a t e p h y s i c i a n s . 63 One o f t h e most i n t e r e s t i n g f i n d i n g s o f t h e p r e s e n t s t u d y i s t h e e x t e n t t o w h i c h t h e emergency d e p a r t m e n t o f L i o n s Gate H o s p i t a l p r o v i d e s p r i m a r y m e d i c a l c a r e as o p p o s e d t o c r i s i s c a r e . R o u g h l y 21 p e r c e n t o f t h e p a t i e n t s p e r c e i v e d t h e i r d i s o r d e r t o be s e v e r e , w h i l e a n o t h e r 39 p e r c e n t f e l t t h e i r c o n d i t i o n t o be i n need o f u r g e n t m e d i c a l c a r e . A l t h o u g h n o t a l l o f t h e p a t i e n t -r e p o r t e d s e v e r e and u r g e n t c a s e s may be g e n u i n e m e d i c a l emergen-c i e s , i t i s e v i d e n t t h a t t h e emergency d e p a r t m e n t a c t s as a t r a u m a - t r e a t m e n t c e n t r e f o r a s u b s t a n t i a l p r o p o r t i o n o f i t s p a t i e n t s , p r o v i d i n g a c u t e c a r e f o r t h e s e r i o u s l y i l l and i n j u r e d . On t h e o t h e r hand, i t i s a l s o e v i d e n t t h a t t h e emergency d e p a r t m e n t s e r v e s as a s u b s t i t u t e f o r -then .iwider . p r i m a r y c a r e s y s t e m . I t has a l r e a d y been n o t e d t h a t p r i v a t e p h y s i c i a n s and t h e i r n o n - a v a i l a b i l i t y a r e major f a c t o r s c o n t r i b u t i n g t o t h e demand f o r emergency d e p a r t m e n t s e r v i c e s among t h e sampled p a t i e n t s . The f a c t t h a t the emergency d e p a r t m e n t i s s u b s t i t u t i n g f o r o t h e r a m b u l a t o r y c a r e r e s o u r c e s i s f u r t h e r h i g h l i g h t e d by the f i n d i n g s t h a t 40 p e r c e n t o f t h e p a t i e n t s s t a t e d t h a t t h e i r d i s o r d e r i s n o n u r g e n t , and t h a t n o n u r g e n t p a t i e n t s a r e as l i k e l y as o t h e r s t o go d i r e c t l y t o t h e h o s p i t a l w i t h o u t f i r s t a t t e m p t i n g t o c o n t a c t a p h y s i c i a n . A d d i t i o n a l e v i d e n c e t h a t t h e emergency d e p a r t m e n t has g a i n e d wide a c c e p t a n c e as a s o u r c e o f p r i m a r y m e d i c a l c a r e i s p r o v i d e d by t h e f i n d i n g t h a t t h e r e a r e no s i g n i -f i c a n t d i f f e r e n c e s i n p a t i e n t - r e p o r t e d u r g e n c y o f c o m p l a i n t s among p a t i e n t s w i t h d i f f e r e n t p a t t e r n s o f o b t a i n i n g m e d i c a l c a r e . 64 P a t i e n t s a r e as l i k e l y t o use t h e emergency d e p a r t m e n t f o r non-u r g e n t c o n d i t i o n s r e g a r d l e s s o f (1) whether or n o t t h e y have a f a m i l y d o c t o r ; (2) whether t h e y make o n l y one o r m u l t i p l e emergency d e p a r t m e n t v i s i t s ; (3) w h i c h m e d i c a l r e s o u r c e i s used f o r volume p u r p o s e s ; or (4) w h i c h m e d i c a l r e s o u r c e i s u t i l i z e d f o r c e n t r a l i z i n g p u r p o s e s . I t a p p e a r s t h a t t h e emer-gency d e p a r t m e n t o f L i o n s Gate H o s p i t a l p r o v i d e s as much p r i m a r y m e d i c a l c a r e as i t does a c u t e emergency c a r e , e s p e c i a l l y i n view o f t h e f a c t t h a t p a t i e n t s w i t h s c h e d u l e d a p p o i n t m e n t s a r e a l s o t r e a t e d i n t h i s f a c i l i t y . I m p l i c a t i o n s The p r e s e n t s t u d y e m p h a s i z e s t h e d i v e r s i t y o f p a t t e r n s o f m e d i c a l c a r e f o l l o w e d by t h e p a t i e n t s o f L i o n s G a t e ' s emergency d e p a r t m e n t . To t h u s i d e n t i f y d i f f e r e n t t y p e s o f u s e r s i s t o s u g g e s t t h a t t h i s f a c i l i t y has d i f f e r e n t i a l r e s p o n s i b i l i t i e s t o i t s p a t i e n t s , w i t h c o r r e s p o n d i n g i m p l i c a t i o n s f o r t h e o r g a n i z a -t i o n o f t h e d e p a r t m e n t . I t i s n o t s u g g e s t e d , however, t h a t t h e emergency d e p a r t m e n t s h o u l d a u t o m a t i c a l l y accommodate i t s e l f t o t h e d i f f e r e n t p a t t e r n s o f u t i l i z a t i o n o f i t s p a t i e n t s . R a t h e r , t h o s e r e s p o n s i b l e f o r p l a n n i n g t h e f u t u r e o f t h i s f a c i l i t y must f i r s t s p e c i f y t h e g o a l s o f t h e emergency d e p a r t m e n t . In p a r t i c u l a r , agreement must be r e a c h e d as t o whether t h i s f a c i l i t y i s t o be r e s t r i c t e d t o t h e p r o v i s i o n o f a c u t e emergency c a r e , or whether t h e emergency d e p a r t m e n t i s t o c o n t i n u e t o s u b s t i t u t e f o r the,-wider_primary; ; 65 c a r e s y s t e m ( K l e i n m a n , T a n n e r , S o o d a l t e r , C u t l e r & W e i s s , 1975) . One a l t e r n a t i v e a v a i l a b l e t o L i o n s Gate H o s p i t a l i s t o r e s t r i c t t h e usage o f i t s emergency d e p a r t m e n t t o t h o s e p a t i e n t s w i t h m e d i c a l e m e r g e n c i e s , and t o r e j e c t p a t i e n t s w i t h n o n u r g e n t c o n d i t i o n s . A s i d e from t h e l e g a l i s s u e s i n v o l v e d , t h i s o p t i o n has t h e d i s a d v a n t a g e o f i g n o r i n g t h e f a c t t h a t t h e u t i l i z a t i o n o f emergency d e p a r t m e n t s f o r n o n u r g e n t c a r e i s due l a r g e l y t o t h e i n a c c e s s i b i l i t y o f o t h e r s o u r c e s o f a m b u l a t o r y m e d i c a l c a r e . P r o c e d u r e s t o e x c l u d e n o n u r g e n t p a t i e n t s f r o m t h e emergency d e p a r t m e n t , w i t h o u t p r o v i d i n g a l t e r n a t i v e s o u r c e s o f c a r e w h i c h a r e b o t h a c c e s s i b l e and d e s i r a b l e t o t h e p a t i e n t s , a r e n o t l i k e l y t o s u c c e e d . —" Thus, t h e r e j e c t i o n o f n o n u r g e n t p a t i e n t s by L i o n s Gate H o s p i t a l does n o t seem f e a s i b l e u n t i l s u b s t a n t i a l c h a n g es a r e made i n t h e ? w i d e r a m b u l a t o r y h e a l t h c a r e s y s t e m . O p t i o n s a r e a v a i l a b l e , however, w h i c h w i l l a s s i s t t h e emergency d e p a r t m e n t t o f u l f i l l t h e d i f f e r e n t i a l r e s p o n s i b i l i t i e s w h i c h a r e imposed 1_. Community h e a l t h c e n t r e s , as p r o p o s e d by t h e H a s t i n g s commit-t e e , r e p r e s e n t one a l t e r n a t i v e s o u r c e o f c a r e w h i c h may r e d u c e th e demand f o r n o n u r g e n t c a r e a t emergency d e p a r t m e n t s . A t p r e s e n t , however, few s t u d i e s have been p u b l i s h e d w h i c h d o c u -ment the e f f e c t o f a community o r n e i g h b o u r h o o d h e a l t h c e n t r e on a community's u t i l i z a t i o n o f emergency d e p a r t m e n t s . One i s s u e r e g a r d i n g community h e a l t h c e n t r e s w h i c h must be c l o s e l y examined by h e a l t h c a r e p l a n n e r s and t h e m e d i c a l p r o f e s s i o n i s t h e f o r m o f payment; t h e p r e s e n t f e e - f o r - s e r v i c e payment s y s -tem i s i n c o m p a t i b l e w i t h t h e o b j e c t i v e s o f community h e a l t h c e n t r e s. 66 upon i t by t h e v a r i e t y o f p a t t e r n s o f c a r e f o l l o w e d by i t s p a -t i e n t s . One p o s s i b l e o p t i o n f o r f u t u r e m o d i f i c a t i o n or e x p a n s i o n o f t h e emergency d e p a r t m e n t i s o u t l i n e d by Fenhagen, Webb, P e a r s o n & Thompson ( 1 9 7 3 ) : As u t i l i z a t i o n i n c r e a s e s , more and more i n s t i t u -t i o n s w i l l f a c e t h e d e c i s i o n o f c o n t i n u a l l y en-l a r g i n g t h e emergency d e p a r t m e n t or making some k i n d o f h e a l t h s e r v i c e o r g a n i z a t i o n a l d i s t i n c t i o n between u r g e n t and n o n u r g e n t a m b u l a t o r y p a t i e n t c a r e . B e c a u se o f t h e e x p e n s e s i n c u r r e d w i t h t h e f o r m e r c o u r s e o f a c t i o n , many f a c i l i t i e s may soon r e a c h a l e v e l o f u t i l i z a t i o n w h i c h would w a r r a n t t h e l a t t e r a l t e r n a t i v e (p.106) . The d e c i s i o n o f whether t o make a f o r m a l o r g a n i z a t i o n a l d i s -t i n c t i o n between u r g e n t and n o n u r g e n t c a r e i s c r u c i a l ; few t r a -d i t i o n a l l y o r g a n i z e d emergency d e p a r t m e n t s can c l a i m t h e f a c i l i t i e s and s t a f f i n g r e q u i r e d t o p r o v i d e b o t h e f f e c t i v e c r i s i s c a r e and c o m p r e h e n s i v e p r i m a r y m e d i c a l c a r e . The emergency d e p a r t m e n t i s l i k e l y t o be an i m p e r s o n a l and e x p e n s i v e s o u r c e o f p r i m a r y m e d i c a l c a r e . In a d d i t i o n , t h e s u b s t a n t i a l number o f p a t i e n t s who r e l y on t h e emergency d e p a r t m e n t f o r t h e t r e a t m e n t o f n o n u r g e n t c o n d i t i o n s may d e t r a c t from i t s a b i l i t y t o p r o v i d e a c u t e m e d i c a l c a r e t o t h e s e r i o u s l y i l l and i n j u r e d ( G i b s o n , 1973; H a m i l t o n , 1974). Emergency d e p a r t m e n t v i s i t s t o L i o n s Gate H o s p i t a l have i n c r e a s e d s u b s t a n t i a l l y i n r e c e n t y e a r s , from 21,789 v i s i t s i n 1966 t o 39,025 v i s i t s i n 1974. As n o t e d e a r l i e r , t h e s e v i s i t s a r e n o t r e s t r i c t e d t o e p i s o d i c t r e a t m e n t o f c r i s i s o r u n p r e d i c -t a b l e m e d i c a l e v e n t s . R a t h e r , t h e emergency d e p a r t m e n t has e v o l v e d i n t o a major s o u r c e o f p r i m a r y m e d i c a l c a r e . M o r e o v e r , t h i s f a c i l i t y has been i d e n t i f i e d as an i m p o r t a n t and c o n t i n u i n g s o u r c e o f c a r e i n t h e m e d i c a l c a r e p a t t e r n s o f many o f i t s 67 p a t i e n t s , b o t h as a c e n t r a l a n d / o r volume s o u r c e o f c a r e . The above f i n d i n g s s u g g e s t t h a t f u t u r e p l a n s f o r e i t h e r t h e m o d i f i c a t i o n o r e x p a n s i o n o f L i o n s G a t e ' s emergency d e p a r t m e n t s h o u l d i n c l u d e t h e e s t a b l i s h m e n t w i t h i n t h e emergency d e p a r t m e n t o f a , w a l k - i n a m b u l a t o r y c l i n i c . T h i s c l i n i c would f u n c t i o n as a p r i m a r y c a r e f a c i l i t y t o r e l i e v e t h e emergency a r e a o f b o t h n o n u r g e n t c a s e s and s c h e d u l e d a p p o i n t m e n t s . S i n c e a p p o i n t m e n t s would n o t be n e c e s s a r y , t h e p r i m a r y c a r e c l i n i c would be as a c c e s s i b l e as t h e p r e s e n t emergency d e p a r t m e n t , as w e l l as h a v i n g t h e p o t e n t i a l t o o f f e r more p e r s o n a l i z e d , c o n t i n -uous and c o m p r e h e n s i v e c a r e . T h i s o r g a n i z a t i o n a l d i s t i n c t i o n between c r i s i s and p r i m a r y m e d i c a l c a r e w i l l a l l o w t h e h o s p i t a l t o r e s p o n d t o t h e v a r i a t i o n s o f need w h i c h i t s p a t i e n t s e x h i b i t . In e s s e n c e , t h e above model c a l l s f o r the emergency d e p a r t -ment t o be r e p l a c e d by an a m b u l a t o r y c a r e d e p a r t m e n t , c o n s i s t i n g o f an emergency c e n t r e and a p r i m a r y c a r e c l i n i c . An i m p o r t a n t component o f t h e model i s a s y s t e m o f m e d i c a l t r i a g e , t h e o b j e c -t i v e o f w h i c h i s t o p r o v i d e i m m e d i a t e , c o n c i s e m e d i c a l e v a l u a t i o n o f a l l i n c o m i n g p a t i e n t s , i d e n t i f i c a t i o n o f t h e n a t u r e o f t h e p a t i e n t s ' c o m p l a i n t s and a p p r o p r i a t e r e f e r r a l t o e i t h e r t h e emergency c e n t r e or p r i m a r y c a r e c l i n i c . S e v e r e and u r g e n t p r o b l e m s would be t r e a t e d i n t h e emergency c e n t r e , a l l o w i n g t h i s f a c i l i t y t o r e t u r n t o i t s t r a d i t i o n a l r o l e o f p r o v i d i n g a c u t e m e d i c a l c a r e , w h i l e n o n u r g e n t c a s e s would become t h e r e s p o n s i -b i l i t y o f t h e p r i m a r y c a r e c l i n i c . 68 The p r i m a r y c a r e c l i n i c c o u l d h a n d l e n o t o n l y n o n u r g e n t c a s e s r e f e r r e d by t h e m e d i c a l t r i a g e o f f i c e r , b ut c o u l d a l s o be r e s p o n s i b l e f o r r o u t i n e f o l l o w - u p c a r e b o t h f o r t h o s e p a t i e n t s who u t i l i z e t h e a m b u l a t o r y c a r e d e p a r t m e n t f o r c e n t r a l i z i n g p u r p o s e s and t h o s e who do n o t p a t t e r n t h e i r c a r e a r o u n d a c e n t r a l s o u r c e . T h i s p r o c e d u r e would a l l o w t h e h o s p i t a l t o p r o v i d e more c o n t i n u o u s c a r e t h a n i s .'presently p o s s i b l e t o t h o s e p a t i e n t s who r e l y on t h e h o s p i t a l as an i m p o r t a n t s o u r c e o f a m b u l a t o r y m e d i c a l c a r e . More c o m p r e h e n s i v e c a r e c o u l d a l s o be p r o v i d e d ; t h e t r a d i t i o n a l l y o r g a n i z e d emergency d e p a r t m e n t i s n o t c o n d u c i v e t o t h e p r o v i s i o n o f e d u c a t i o n a l and p r e v e n t i v e h e a l t h s e r v i c e s . P a t i e n t s who c e n t r a l i z e t h e i r c a r e a r o u n d a p r i v a t e p h y s i c i a n c o u l d a l s o be g i v e n f o l l o w - u p c a r e i n t h e p r i m a r y c a r e c l i n i c i n t h o s e c a s e s i n w h i c h t h e t r e a t i n g p h y s i c i a n d e c i d e d i t a p p r o p r i a t e f o r r e a s o n s o f c o n t i n u i t y o f c a r e . In any e v e n t , t h e s e r v i c e s p r o v i d e d by t h e a m b u l a t o r y c a r e d e p a r t m e n t s h o u l d be c o o r d i n a t e d w i t h t h e o t h e r s o u r c e s o f c a r e w h i c h t h e p a t i e n t s u t i l i z e ; f o r t h e m a j o r i t y o f p a t i e n t s , t h i s r e q u i r e m e n t would e n t a i l c o -o r d i n a t i n g t h e s e r v i c e s o f t h e a m b u l a t o r y c a r e d e p a r t m e n t w i t h t h e s e r v i c e s o f p r i v a t e p h y s i c i a n s . The i s s u e o f s t a f f i n g an a m b u l a t o r y c a r e d e p a r t m e n t i s a complex one, and beyond th e scope o f t h e p r e s e n t p r o j e c t . In g e n e r a l t e r m s , however, the emergency c e n t r e c o u l d be s t a f f e d by p h y s i c i a n s w i t h f o r m a l t r a i n i n g and e x p e r i e n c e i n emergency m e d i c i n e , w h i l e t h e p r i m a r y c a r e c l i n i c c o u l d be s t a f f e d by p h y s i c i a n s w i t h a g e n e r a l or f a m i l y p r a c t i c e b a c k g r o u n d , as w e l l as f rom s u c h s p e c i a l t i e s as i n t e r n a l m e d i c i n e and p e d i a t r i c s . The t r i a g e f u n c t i o n c o u l d be p e r f o r m e d by a s p e c i a l l y t r a i n e d 69 n u r s e or p a r a m e d i c , o r by a q u a l i f i e d p h y s i c i a n (Fenhagen, Webb, P e a r s o n & Thompson, 1973). In summary, t h e a m b u l a t o r y c a r e d e p a r t m e n t r e p r e s e n t s an o r g a n i z a t i o n a l s t r u c t u r e w h i c h would a s s i s t L i o n s Gate H o s p i t a l t o f i t i t s s e r v i c e s t o t h e m e d i c a l c a r e needs w h i c h i t s p a t i e n t s e x h i b i t . E f f e c t i v e c r i s i s c a r e would be p r o v i d e d i n an emer-gency c e n t r e d e s i g n e d and u s e d s o l e l y f o r t h i s p u r p o s e . Compre-h e n s i v e , and i f need be, c o n t i n u o u s p r i m a r y c a r e would be p r o -v i d e d i n a s e p a r a t e a r e a , a l l o w i n g t h e h o s p i t a l t o u n d e r t a k e g r e a t e r r e s p o n s i b i l i t y f o r t h e c a r e o f t h o s e p a t i e n t s who c e n t r a l i z e t h e i r c a r e a r o u n d t h e h o s p i t a l . H o s p i t a l - b a s e d p r i m a r y c a r e has s t e a d i l y i n c r e a s e d due t o t h e i n a c c e s s i b i l i t y o f o t h e r a m b u l a t o r y c a r e s o u r c e s ; h o s p i t a l and p a t i e n t s a l i k e would b e n e f i t from an o r g a n i z a t i o n a l a r r a n g e m e n t w h i c h a l l o w s h i g h q u a l i t y c a r e f o r b o t h a c u t e and n o n u r g e n t p a t i e n t s . 70 BIBLIOGRAPHY A l l e n , A.B., B a r n a r d , B.G., F a l k , W., H i g g s , E.R., and M c C r a c k e n , J.G. A s t u d y o f w a i t i n g time i n an emergency d e p a r t m e n t . C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l , 1973, 109 ( 5 ) , 373-376. A l p e r t , J . J . , Kosa, J . , H a g g e r t y , R.J., R o b e r t s o n , L., and H e a g a r t y , M.C. The t y p e s o f f a m i l i e s t h a t use an emergency c l i n i c . M e d i c a l C a r e , 1969, V I I ( 2 ) , 55-61. A r o n o v i t c h , S . I . C o m p a r i s o n s o f Emergency Department U t i l i z a -t i o n i n P r e d o m i n a n t l y R u r a l A r e a s o f M a r y l a n d . T h e s i s s u b m i t t e d t o the S c h o o l o f Hyg i e n e and P u b l i c H e a l t h o f The J o h n s H o p k i n s U n i v e r s i t y i n c o n f o r m i t y w i t h t h e r e q u i r e m e n t s f o r t h e d e g r e e o f D o c t o r o f S c i e n c e . B a l t i m o r e , M a r y l a n d . J a n u a r y , 1973. A t t e r b u r y , C.E., W e i l , T.P., and D o n n e l l , H.D. J r . F a c t o r s a f f e c t i n g emergency room u t i l i z a t i o n . S o u t h e r n M e d i c a l  J o u r n a l , 1968 ( O c t o b e r ) , 61, 1061-1067. B a a r s , C.M. Summary of emergency s u r v e y a t R i v e r s i d e H o s p i t a l , O t t a w a . C a n a d i a n F a m i l y P h y s i c i a n , 1969 ( O c t o b e r ) , 15, 129-133 . B a i n , S., and J o h n s o n , S. Use and abuse o f h o s p i t a l emergency d e p a r t m e n t s . C a n a d i a n F a m i l y P h y s i c i a n , 1971 (May), 17, 33-36. B a l t z a n , M.A. The new r o l e o f t h e h o s p i t a l emergency d e p a r t m e n t . C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l , 1972, 106 ( 3 ) , 249-256. B a r t h , N.K. E x a m i n a t i o n o f S e l e c t e d C h a r a c t e r i s t i c s o f Emer-gency D e p a r t m e n t A c t i v i t y : Ottawa C i v i c H o s p i t a l . T h e s i s s u b m i t t e d t o t h e S c h o o l o f H o s p i t a l A d m i n i s t r a t i o n i n P a r t i a l F u l f i l l m e n t o f t h e R e q u i r e m e n t s f o r t h e M a s t e r ' s Degree i n H o s p i t a l A d m i n i s t r a t i o n , U n i v e r s i t y o f Ottawa, March, 1967. 71 B e c k , R.G. E c o n o m i c c l a s s a n d a c c e s s t o p h y s i c i a n s e r v i c e s u n d e r p u b l i c m e d i c a l c a r e i n s u r a n c e . I n t e r n a t i o n a l J o u r n a l o f H e a l t h S e r v i c e s , 1 9 7 3 , 3 ( 3 ) , 3 4 1 - 3 5 5 . B e l o f f , J . S . A d a p t i n g t h e h o s p i t a l e m e r g e n c y s e r v i c e o r g a n i -z a t i o n t o p a t i e n t n e e d s . H o s p i t a l s , J . A . H . A . , 1 9 6 8 , 42 ( 8 ) , 6 5 - 6 9 . B e r g m a n , A . B . a n d H a g g e r t y , R . J . T h e e m e r g e n c y c l i n i c : a s t u d y o f i t s r o l e i n a t e a c h i n g h o s p i t a l . A m e r i c a n  J o u r n a l o f D i s e a s e s o f C h i l d r e n , 1 9 6 2 ( J u l y ) , 1 0 4 , 3 6 - 4 4 B e r m a n , J . I . , a n d L u c k , E. P a t i e n t s ' e t h n i c b a c k g r o u n d s a f f e c t u t i l i z a t i o n . H o s p i t a l s , J . A . H . A . , 1 9 7 1 , 45 ( 1 4 ) , 6 4 - 6 8 . B l a c k w e l l , B. Why p a t i e n t s come t o a c a s u a l t y d e p a r t m e n t . The L a n c e t , 1 9 6 2 ( F e b r u a r y 1 7 ) , 1, 3 6 9 - 3 7 1 . B o d e n h e i m e r , T.S. P a t t e r n s o f A m e r i c a n a m b u l a t o r y c a r e . I n q u i r y , 1 9 7 0 , V I I (3 ) , 2 6 - 3 7 . B o o k e r , J . , a n d V a n s a n t , J . H . T h e c h a n g i n g s t a t u s o f t h e e m e r -g e n c y r o o m . V i r g i n i a M e d i c a l M o n t h l y , 1 9 6 9 , 96 (7) , 3 9 7 - 4 0 0 . B r a d h a m , G.B. An a n a l y s i s o f 2 , 4 1 8 e m e r g e n c y r o o m a d m i s s i o n s . T h e J o u r n a l o f t h e S o u t h C a r o l i n a M e d i c a l A s s o c i a t i o n , 1 9 6 5 , 61 ( 5 ) , 1 2 7 - 1 3 0 . B r a d h a m , G.B. F o l l o w - u p a n a l y s i s o f e m e r g e n c y r o o m a d m i s s i o n s T h e J o u r n a l o f t h e S o u t h C a r o l i n a M e d i c a l A s s o c i a t i o n , 1 9 6 7 , 63 (9) , 3 2 3 - 3 2 5 . B r o w n e , M.K. An a n a l y s i s o f p a t i e n t s a t t e n d i n g t h e c a s u a l t y d e p a r t m e n t . The B r i t i s h J o u r n a l o f C l i n i c a l P r a c t i c e , 1 9 6 3 , 17 ( 6 ) , 3 2 5 - 3 2 8 . C h a i t o n , A. T r e n d s i n e m e r g e n c y d e p a r t m e n t u t i l i z a t i o n . C a n a -d i a n F a m i l y P h y s i c i a n , 1 9 7 5 ( J a n u a r y ) , 21 ( 1 ) , 1 1 5 - 1 2 2 . 72 Chipman, M.L. The demand f o r emergency s e r v i c e s : a s t u d y from the V i c t o r i a G e n e r a l H o s p i t a l . The Nova S c o t i a M e d i c a l  B u l l e t i n , 1971 ( A p r i l ) , 5_0, 39-40 . D a v i s , E.H. S t u d y shows who comes t o t h e emergency room and what happens t o them a f t e r t h e y g e t t h e r e . Modern H o s p i t a l , 1973 , 120 (6) , 84-87 . D i x o n , C.W., Emery, G.M., and S p e a r s , G.F.S. C a s u a l t y d e p a r t m e n t u t i l i s a t i o n s u r v e y . The New Z e a l a n d M e d i c a l J o u r n a l , 1970, 71 (456), 272-279. Duncan, M. How t o e v a l u a t e emergency room c a r e . The Modern  H o s p i t a l , 1962, 99_ ( 5 ) , 103-106 and 168. Emergency M e d i c a l S e r v i c e s Sub-Committee. Emergency M e d i c a l  S e r v i c e s . R e p o r t t o A d v i s o r y Committee o f t h e G r e a t e r V a n c o u v e r R e g i o n a l H o s p i t a l D i s t r i c t , 1970. F a i r l e y , J . , and Hewett, W.C. S u r v e y o f c a s u a l t y d e p a r t m e n t s i n G r e a t e r London. B r i t i s h M e d i c a l J o u r n a l , 1969, 2_ (5653 ) , 375-377 . Fenhagen, H.P., Webb, S.B. J r . , P e a r s o n , D.A., and Thompson, J.D. Emergency m e d i c a l s e r v i c e s and t h e h o s p i t a l : a s t a t e w i d e a n a l y s i s . H o s p i t a l A d m i n i s t r a t i o n , 1973 , 1_8 ( 4 ) , 92-109 . F r e c h e t t e , G. Emergency c a r e and h o s p i t a l c e n t r e s . D i m e n s i o n s  i n H e a l t h S e r v i c e , 1975 , 52_ ( 2 ) , 45-47 . F r e y , C.F., H i n d s , R . J . , Dow, R.W., and T u r c o t t e , J.G. 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S t r a t m a n n , W.C., and U l l m a n , R. A s t u d y o f consumer a t t i t u d e s a b o u t h e a l t h c a r e : the r o l e o f t h e emergency room. M e d i c a l C a r e , 1975, X I I I ( 1 2 ) , 1033-1043. Taubenhaus, L . J . The n o n s c h e d u l e d p a t i e n t i n t h e emergency d e p a r t -ment and w a l k - i n c l i n i c . B u l l e t i n o f t h e New York Academy  of M e d i c i n e , 1973, 49 ( 5 ) , 419-426. T e g l a s , A.L. P a t t e r n s o f emergency p r a c t i c e . C a n a d i a n F a m i l y  P h y s i c i a n , 1969 ( O c t o b e r ) , 15_, 56-59. Thompson, J.D., and Webb, S.B. J r . E f f e c t s o f t h e emergency d e p a r t m e n t on h o s p i t a l i n p a t i e n t s e r v i c e s : a s t a t e w i d e a n a l y s i s . I n q u i r y , 1973, X ( 2 ) , 19-26. T o r r e n s , P.R., and Yedvab, D.G. S t u d y shows E.R. t r e a t m e n t v a r i e s w i t h make-up o f l o c a l p o p u l a t i o n . H o s p i t a l T o p i c s , 1966 , 44 (12) , 71-73 . T o r r e n s , P.R., and Yedvab, D.G. Income and r e s i d e n c e a r e k e y s t o E.R. usage p a t t e r n . The Modern H o s p i t a l , 1967 , 108 (2) , 113-116. T o r r e n s , P.R., and Yedvab, D.G. V a r i a t i o n s among emergency room p o p u l a t i o n s : a c o m p a r i s o n of f o u r h o s p i t a l s i n New York C i t y . M e d i c a l C a r e , 1970, V I I I ( 1 ) , 60-75. U l l m a n , R., B l o c k , J.A., and S t r a t m a n n , W.C. An emergency room's p a t i e n t s : t h e i r c h a r a c t e r i s t i c s and u t i l i z a t i o n o f h o s p i t a l s e r v i c e s . M e d i c a l C a r e , 1975, 13 ( 1 2 ) , 1011-1020. Urman, J.D., and Lamkin, K.R. Emergency room u t i l i z a t i o n a t S h a ' a r e Zedek H o s p i t a l i n J e r u s a l e m . M e d i c a l C a r e , 1973 , 11 ( 6 ) , 491-500. 81 Vaughan, H.F., J r . , and Gamester, C.E. H o s p i t a l emergency room u t i l i z a t i o n i n M i c h i g a n . I n q u i r y , 1 9 6 6 ( a ) , I I I ( 2 ) , 34-56. Vaughan, H.F., J r . , and Gamester, C.E. Why p a t i e n t s use h o s p i t a l emergency d e p a r t m e n t s . H o s p i t a l s , J.A.H.A., 1966(b) ( O c t . 1) , 40, 59-62 and 121 . V ayda, E., Gent, M., and H e n d e r s h o t , A. Emergency d e p a r t m e n t use a t two H a m i l t o n h o s p i t a l s . C a n a d i a n M e d i c a l A s s o c i a t i o n  J o u r n a l , 1975, 112 ( 8 ) , 961-965. V a y d a , E . , G e n t , M., a n d P a i s l e y , L . A n e m e r g e n c y d e p a r t m e n t t r i a g e m o d e l b a s e d on p r e s e n t i n g c o m p l a i n t s . C a n a d i a n  J o u r n a l o f P u b l i c H e a l t h , 1 9 7 3 ( a ) , 64 ( 3 ) , 2 4 6 - 2 5 3 . Vayda, E., Gent, M., and P a i s l e y , L. Emergency s e r v i c e s a t H a m i l t o n ' s St.. J o s e p h ' s H o s p i t a l . O n t a r i o M e d i c a l Review, 1973 ( b ) , 40_ ( 1 1 ) , 699-706. Vayda, E., Gent, M., and P a i s l e y , L. S o c i a l c l a s s and emergency d e p a r t m e n t u t i l i z a t i o n . C a n a d i a n F a m i l y P h y s i c i a n , 1975, 21 (2) , 117-125 . W a l k e r , L . L . The emergency d e p a r t m e n t as t h e e n t r y p o i n t i n t o t h e h e a l t h c a r e s y s t e m . H o s p i t a l T o p i c s , 1975 (a) , 5_3_ (2) , 46-47 and 61. W a l k e r , L . L . Why do p a t i e n t s use t h e emergency room. H o s p i t a l  T o p i c s , 1975 ( b ) , 5_3 ( 3 ) , 19-21 and 45. Webb, M.L. The Emergency M e d i c a l C a r e System i n a M e t r o p o l i t a n A r e a . T h e s i s s u b m i t t e d t o t h e S c h o o l o f H y g i e n e and P u b l i c H e a l t h of The Johns H o p k i n s U n i v e r s i t y i n C o n f o r m i t y w i t h t h e R e q u i r e m e n t s f o r t h e Degree o f D o c t o r o f P u b l i c H e a l t h , B a l t i m o r e , M a r y l a n d , December, 1969. Weinerman, E.R., and. Edwards, H.R. ' T r i a g e ' s y s t e m shows p r o m i s e i n management of emergency d e p a r t m e n t l o a d . H o s p i t a l s ,  J.A.H.A., 1964, 38 ( 2 2 ) , 55-62. 82 Weinerman, E.R., R a t n e r , R.S., R o b b i n s , A., and L a v e n h a r , M.A. Y a l e s t u d i e s i n a m b u l a t o r y m e d i c a l c a r e : V. D e t e r m i n a n t s o f use o f h o s p i t a l emergency s e r v i c e s . A m e r i c a n J o u r n a l  o f P u b l i c H e a l t h , 1966 , 5_6 ( 7 ) , 1037-1056. Weinerman, E.R., R u t z e n , S.R., and P e a r s o n , D.A. E f f e c t s o f m e d i c a l ' t r i a g e ' i n h o s p i t a l emergency s e r v i c e . P u b l i c  H e a l t h R e p o r t s , 1965 , 80_ ( 5 ) , 389-399 . White, H.A., and O'Connor, P.A. Use o f t h e emergency room i n a community h o s p i t a l . P u b l i c H e a l t h R e p o r t s , 1970, 8_5_ (2) , 163-168. W i l s o n , F.A., and N e u h a u s e r , D. H e a l t h S e r v i c e s i n t h e U n i t e d  S t a t e s . C a m b r i d g e , Mass..: B a l l i n g e r P u b l i s h i n g Company, 1974 . W i n g e r t , W.A., F r i e d m a n , D.B., and L a r s o n , W.R. The demo-g r a p h i c a l and e c o l o g i c a l c h a r a c t e r i s t i c s o f a l a r g e u r b a n p e d i a t r i c o u t p a t i e n t p o p u l a t i o n and i m p l i c a t i o n s f o r im-p r o v i n g community p e d i a t r i c c a r e . A m e r i c a n J o u r n a l o f  P u b l i c H e a l t h , 1968 , 58_ ( 5 ) , 859-876. Wood, J . , P r y b i l , L., and Simpson, J . An a p p r o a c h t o s t u d y i n g emergency d e p a r t m e n t u t i l i z a t i o n . V i r g i n i a M e d i c a l  M o n t h l y , 1974, 101 ( 6 ) , 458-464. 83 A p p e n d i x 1 P e r c e n t a g e I n c r e a s e i n E m e r g e n c y D e p a r t m e n t V i s i t s t o H o s p i t a l s i n t h e U n i t e d S t a t e s  H O S P I T A L S I N V E S T I G A T O R T I M E P E R I O D P E R C E N T A G E P E R I O D I N YEARS I N C R E A S E New Y o r k H o s p i t a l New Y o r k N . Y . R e e d & 1955-R e a d e r ( 1 9 6 7 ) 1 9 6 5 11 56 R e x H o s p i t a l R a l e i g h , N . C . H i l l e n m e y e r 1964-( 1 9 7 4 ) 1 9 7 3 10 63 F r e d e r i c k M e m o r i a l F r e d e r i c k, Md . G o l o m b & 1967-H e r r o l d ( 1 9 7 4 ) 1 9 7 2 7 5 * Y a l e -New H a v e n New H a v e n , C o n n . W e i n e r m a n & 1953-E d w a r d s ( 1 9 6 4 ) 1 9 6 3 11 76 U n i v e r s i t y o f M i c h i g a n M e d i c a l C e n t e r A n n A r b o r , M i c h . F r e y e t a l . ( 1 9 7 0 ) 1 9 5 6 - 5 7 t o 1 9 6 7 - 6 8 12 79 R i c h m o n d R i c h m o n d , Wood 1961-M e m o r i a l V a . e t a l . ( 1 9 7 4 ) 1 9 7 1 11 157 T o u r o I n f i r m a r y New O r l e a n s , L a . J i e d e l ( 1 9 6 5 ) 1954-1 9 6 3 10 2 0 3 A l l e g h e n y G e n e r a l P i t t s b u r g h , P a . M a r i n a k o s & 1935-L a n d g r a f ( 1 9 6 3 ) 1 9 6 2 28 2 1 0 ' M e t h o d i s t I n d i a n a p o l i s , I n d . D u n c a n ( 1 9 6 2 ) 1949-1 9 5 9 11 3 8 0 S t . L u k e ' s M e t h o d i s t C e d a r R a p i d s , I o w a G i t c h e l l ( 1 9 6 6 ) 1950-1 9 6 5 16 3 8 7 * C h i l d r e n ' s H o s p i t a l M e d i c a l C e n t r e B o s t o n , Ma s s . B e r g m a n & 1947-H a g g e r t y ( 1 9 6 2 ) 1 9 6 0 14 1 4 7 2 * * C a l c u l a t e d f r o m d a t a p r e s e n t e d b y t h e i n v e s t i g a t o r . 84 A p p e n d i x 2 P e r c e n t a g e of Emergency D e p a r t m e n t V i s i t s J udged to be N o n - u r g e n t a t H o s p i t a l s i n t h e U n i t e d S t a t e s HOSPITALS Sacramento C o u n t y S a c r a m e n t o , C a l i f . INVESTIGATOR R e i b e r (1965) TIME PERIOD 1 week-y e a r n o t r e p o r t e d PERCENTAGE NON-URGENT 22 11 Ho s p i t a l s Bo s t o n , Mass . K l e i n m a n e t a l . (1975) 9 days i n 1972 28 S t . L o u i s C h i l d r e n ' s St . L o u i s , Mo . Kahn e t a l . (1973). 15 weeks i n 1969 33 71 H o s p i t a l s M e t r o p o l i t a n C h i c a g o G i b s o n (1971) 24 h o u r s i n 1969 35 H o s p i t a l s W a s h i n g t o n , D . C . a r e a D a v i s (1973) 1 we e k i n 1971-72 36 S a g i n a w G e n e r a l Saginaw, M i c h . White & O'Connor (1970) 16 weeks i n 1966-67 36 B e t h I s r a e l B o s t o n , Ma s s . Lee e t a. (1960) 4 weeks i n 1957 38 265 H o s p i t a l s B a r n e s -M c M i l l a n S t r a t i f i e d random sample i n U . S . S t . Lou i s, Mo . Skudder e t a l . (1961) P e r k o f f & A n d e r s o n (1970) 1 week i n 1958 2 months i n 1968 42 43 Me t h o d i s t I n d i a n a p o l i s , Ind . Duncan (1962) 2 months i n 1960 44 F . F . Thomp son Memor i a l C a n a n d a i g u a , J a c o b s N. Y. e t a l . (1972) 12 months i n 1969-70 44 22 M e t r o p o l i t a n H o s p i t a l s B a l t i m o r e Webb (1969) 1 & 2 week p e r i o d i n 1968 46 N o r f o l k G e n e r a l N o r f o l k , Va . Booker & V a n s a n t (1969) 5 weeks i n 1968 51 M o r r i s a n i a C i t y B ronx, N . Y . J o n a s e t a l (1976) 2 weeks i n 1970 53 85 A p p e n d i x 2 I N V E S T I G A T O R T I M E P E R I O D P E R C E N T A G E NON-URGENT B a l t i m o r e , Md . B e r m a n & L u c k ( 1 9 7 1 ) 2 w e e k s i n 1 9 6 8 5 5 New H a v e n , C o n n . We i n e r m a n e t a l . ( 1 9 6 6 ) 2 w e e k s i n 1 9 6 4 56 New Y o r k , N . Y . R e e d & R e a d e r ( 1 9 6 7 ) 12 m o n t h s i n 1 9 6 5 5 8 * V i r g i n i a R u d o l f e t a l . ( 1 9 6 9 ) n o t r e p o r t e d 59 R o c h e s t e r , N. Y. a r e a J a c o b s e t a l . ( 1 9 7 1 ) 12 m o n t h s i n 1 9 6 8 63 R i c h m o n d , V a . Wood e t a l . ( 1 9 7 4 ) 1 w e e k i n 1 9 7 2 64 R o c h e s t e r , N . Y . K l u g e e t a l ( 1 9 6 5 ) 1 m o n t h i n 1 9 6 4 65 Bo s t o n , Ma s s . K i r k p a t r i c k & 45 d a y s T a u b e n h a u s ( 1 9 6 7 ) i n 1 9 6 5 69' * C a l c u l a t e d f r o m d a t a p r e s e n t e d b y t h e : . i n v e s t i g a t o r . 86 A p p e n d i x 3 Emergency Department S t u d i e s C o n d u c t e d i n F o r e i g n C o u n t r i e s Due t o t h e l a r g e number o f emergency d e p a r t m e n t s t u d i e s w h i c h have been p u b l i s h e d , t h e l i t e r a t u r e r e v i e w p r e s e n t e d i n th e t e x t o f t h i s r e p o r t i s r e s t r i c t e d t o t h o s e s t u d i e s w h i c h were c o n d u c t e d i n Canada and t h e U n i t e d S t a t e s . N o n e t h e l e s s , i n v e s t i g a t o r s have examined emergency d e p a r t m e n t u t i l i z a t i o n i n s e v e r a l o t h e r c o u n t r i e s . In a c c o r d a n c e w i t h N o r t h A m e r i c a n d a t a , t h e s e s t u d i e s g e n e r a l l y show a d r a m a t i c i n c r e a s e i n t h e t o t a l number o f emergency d e p a r t m e n t v i s i t s , as w e l l as a sub-s t a n t i a l p r o p o r t i o n o f v i s i t s f o r t h e t r e a t m e n t o f n o n - u r g e n t m e d i c a l p r o b l e m s . The i n t e r e s t e d r e a d e r i s r e f e r r e d to s t u d i e s w h i c h have been c o n d u c t e d i n A u s t r a l i a ( H a m i l t o n , W i l k i n s o n and S a n t a m a r i a , 1973; J o n a s , 1974; L o v e l l , K i b b l e , T e n n a n t , Z a b e l l and D u g d a l e , 1975; Mok, 1972; S t a r r , 1973); E n g l a n d ( B l a c k w e l l , 1962; F a i r l y and Hewett, 1969; F r y , 1960; Gampel, 1965; Hardy, 1974; M e s t i t z , 1957; Morgan, W a l k e r , H o l o h a n and R u s s e l l , 1974; P a r r y , C o o p e r , S h e l s w e l l , D u n k e r l e y , Denham and Murray, 1962; P e a s e , 1973); F i n l a n d (Rokkanen, Nummi and A l a n e n , 1974); I r e l a n d ( K a l i s z e r and McCormick, 1975); I s r a e l (Urman and Lamkin, 1973) ; New Z e a l a n d ( D i x o n , Emery and S p e a r s , 1970; G i b b e r t , 1974) ; and S c o t l a n d (Browne, 1963) . 87 A p p e n d i x 4 Q u e s t i o n n a i r e 89 Part 1. Some Questions About Your V i s i t To The Emergency Department The following questions are about your v i s i t to the emergency department. After each question there are some boxes with answers a f t e r them. Please place a checkmark i n the box (•] i n front of the answer which best applies to you. 1, How d i d you get to the emergency department? | |t Private c ar Q s P o l i c e v e h i c l e I 1^  Bus ~ ] u No v e h i c l e : walked Taxi [~], Other, please specify [ L Ambulance 2, Who suggested that you come to an emergency department f o r treatment? | 1 no one, you decided to come I 1^  friends, r e l a t i v e s or neighbours j | 3 private doctor 1 1^  your employer or teacher ( |t h o s p i t a l outpatient department | L ambulance or police | |, other, please specify 3. Why did you come to Lions Gate Hospital's emergency department? | |, i t i s the closest emergency department | | the general reputation of t h i s h o s p i t a l 1 |^  you f e l t that t h i s h o s p i t a l has sp e c i a l f a c i l i t i e s not a v a i l a b l e elsewhere 1 1^  you were treated at t h i s h o s p i t a l i n the past | I, you were sent to t h i s h o s p i t a l by a doctor, h o s p i t a l outpatient department, ambulance, police, employer or teacher | l c other, please specify 4. Did you come to the emergency department because of [~|| an i n j u r y or accident? | 1 an i l l n e s s ? How long was the i n j u r y or i l l n e s s present before your v i s i t to the emergency department? n , Less than 1 hour Q T 13 - 2*4- hours • j 1 - 2 hours Ds 2 - 7 d a y s Q a 3 - 12 hours Q t t More than 7 days Before a r r i v i n g at the emergency department, d i d you think that the i n j u r y or i l l n e s s was: | \ Severe - required immediate treatment r~1n Urgent - required treatment within a few hours I l a Nonurgent - could have been treated by a doctor i n h i s o f f i c e or at your home i f t h i s had been possible Did you attempt to c a l l or see a doctor before coming to the emergency department? Q i I f YES, please answer PART (A) of Question 7. U2x m I f NO, please answer PART (B) of Question 7, PART (A) I When you attempted to c a l l or see a doctor I | The doctor (or his nurse or answering ser-vice) t o l d you to go to the emergency department. Q a The doctor t o l d you that he would meet you at the emergency department. I |, You t r i e d but f a i l e d to contact a doctor. I |^  Other, please specify PART (B): You d i d not attempt to c a l l or see a doctor because you | | f e l t that a doctor was not ava i l a b l e at the time ["I do not have a family doctor 1 j f e l t that immediate care or ho s p i t a l f a c i l i t i e s were required | L were sent to the ho s p i t a l by an employer, teacher, ambulance or police | L f i n d i t easier or more convenient to go to the emergency department than to a doctor's o f f i c e | j other, please specify 91 P a r t 2. Some Q u e s t i o n s About Y o u r U s u a l Methods o f O b t a i n i n g M e d i c a l Ca re We have a sked you s e v e r a l q u e s t i o n s abou t y o u r v i s i t t o t h e emer-gency d e p a r t m e n t . We now want t o f i n d o u t how you u s u a l l y o b t a i n m e d i c a l t r e a t m e n t . 1# Do y o u have a f a m i l y d o c t o r ? Q YES { |^  NO Because you Q , h a v e no t needed a d o c t o r i n t h e p a s t | | , r e c e n t l y moved t o t h e V a n c o u v e r a r e a n ^ p r e f e r t o u s e an emergency depar tment | [ u s u a l l y u s e a h o s p i t a l o u t p a t i e n t depa r tment | p o t h e r , p l e a s e s p e c i f y 2. P l e a s e i n d i c a t e t h e number o f t i m e s you have r e c e i v e d m e d i c a l t r e a t m e n t d u r i n g t h e p a s t 12 months, i n c l u d i n g t h i s v i s i t t o t h e  emergency d e p a r t m e n t . PLEASE NOTEt I f you have b r o u g h t y o u r c h i l d t o t h e emergency d e p a r t m e n t , p l e a s e i n d i c a t e t h e number o f t i m e s your c h i l d has r e c e i v e d m e d i c a l t r e a t m e n t d u r i n g t h e p a s t 12 months. t i m e s Emergency depar tment o f a n o t h e r h o s p i t a l t i m e s 21 t i m e s 22 t i m e s 23 24 t i m e s t i m e s O t h e r , p l e a s e s p e c i f y t i m e s 3. Which m e d i c a l f a c i l i t y i s t h e most i m p o r t a n t t o y o u - t h e one wh ich you have t h e g r e a t e s t f a i t h o r t r u s t i n f o r y o u r m e d i c a l t r e a t m e n t and a d v i c e ? I I, f a m i l y d o c t o r f""l, emergency depa r tment I |^  h o s p i t a l o u t p a t i e n t depa r tment I 1^  o t h e r , p l e a s e s p e c i f y 92 P a r t 3. Some Q u e s t i o n s About You PLEASE NOTE: The f o l l o w i n g q u e s t i o n s ask f o r i n f o r m a t i o n about t h e HEAD o f t h e f a m i l y o f t h e p a t i e n t . The HEAD o f t h e f a m i l y i s : t h e husband r a t h e r t h a n t h e w i f e ; t h e p a r e n t where t h e r e i s one p a r e n t o n l y , w i t h u n m a r r i e d c h i l d r e n ; o r a s i n g l e a d u l t who i s no t a dependent o f h i s / h e r p a r e n t s . 1, Do you l i v e i n t h e m e t r o p o l i t a n Vancouve r a r e a ( V a n c o u v e r C i t y , N o r t h V a n c o u v e r , West V a n c o u v e r , R ichmond, Burnaby , C o q u i t l a m , P o r t C o q u i t l a m , P o r t Moody, New W e s t m i n s t e r , D e l t a , S u r r e y , L a n g l e y , Wh i te Rock)? • , Yes mmrn^ [ ~ . No r - j 2 ? ' F o r how l ong ? | |, L e s s t h a n 1 y e a r 1 - 2 y e a r s _ \ 3 - 5 y e a r s | 1^  6 - 1 0 y e a r s | 1 More than 10 y e a r s • 28 2. How l o n g have yow l i v e d a t y o u r p r e s e n t a d d r e s s ? | |1 L e s s t h a n 6 months [~| + 3 - 5 y e a r s I j., 6 - 1 1 months J-)5 6 - 1 0 y e a r s Q 2Q I 1 - 2 y e a r s L_L More t h a n 10 y e a r s 3. The HEAD o f y o u r f a m i l y i s | |, Employed f u l l - t i m e [~| T Housew i fe | I., Employed p a r t - t i m e S t u d e n t f~] 30 • a Unemployed • 4 R e t i r e d 3 1 4. What i s t h e H i g h e s t grade o r y e a r o f s c h o o l e v e r a t t e n d e d by t h e HEAD o f y o u r f a m i l y ? |~], L e s s t h a n Grade 5 L _ + G rades 12 - 13 | |, G rades 5 - 8 _ ] 4 Some u n i v e r s i t y L _ 32 | j., G rades 9 * 11 I I, U n i v e r s i t y d e g r e e 93 What was your approximate 1973 f a m i l y income; t h a t i s , the combined wages, s a l a r i e s , government p lans ( w e l f a r e , p e n s i o n s , e t c . ) , i n t e r e s t and investments o f a l l members o f your f a m i l y who l i v e w i t h you? Less than $ 3 , 0 0 0 • , $ 3 , 0 0 0 - $4,999 • a $ 5 , 0 0 0 - $6,999 • t $7,000 - $9,999 • 4 $10,000 - $14,999 f~), $15,000 and over • 3 3 PLEASE NOTEi The remain ing q u e s t i o n s ask f o r i n f o r m a t i o n about the PATIENT. 6 . I s the p a t i e n t Q ( Male? Q Female? 7. What i s the p a t i e n t ' s age? I | t 1 year or l e s s • 4 2 - 4 years 5 - 1 ^ y e a r s LZ3t 15 - 24 years Q . 2 5 - 44 y e a r s Q . ^ 5 - 64 years 6 5 years or over 8 , What i s the p a t i e n t ' s m a r i t a l s ta tus? I I, S i n g l e , under 1 5 y e a r s o f age I |.t S i n g l e , 1 5 years o f age o r over I |3 Now M a r r i e d I | Widowed, D i v o r c e d or Separated 9 . Was the p a t i e n t born i n Canada? Q . YES • •*» 10. To what e t h n i c o r c u l t u r a l group d i d the p a t i e n t o r h i s / h e r a n c e s t o r (on the male s i d e ) belong on coming t o t h i s c o n t i n e n t ? • , B r i t i s h I s l e s I l3 French [Hi German • + I t a l i a n f l j F i n n i s h S c a n d i n a v i a n * | \ Nether lands | |w U k r a i n i a n Q , J e w i s h • , P o l i s h I I,, Chinese I I , Japanese ("H Hungar ian I L R u s s i a n I |.„ C z e c h o s l o v a k i a n • „ N a t i v e I n d i a n I I., O t h e r , p lease s p e c i f y * i n c l u d e s D a n i s h , I c e l a n d i c , Norwegian and Swedish • 3 * • 35 • 3 6 • 37 B 3 8 3 9 THANK YOU VERY MUCH FOR YOUR CO-OPERATION 94 A p p e n d i x 5 T e m p o r a l V a r i a t i o n s i n P a t i e n t s ' M e d i c a l C o m p l a i n t s As n o t e d i n t h e t e x t o f t h i s r e p o r t , a p p r o p r i a t e s t a f f i n g a r r a n g e m e n t s f o r t h e emergency d e p a r t m e n t depend i n p a r t upon t h e p a t i e n t mix o f t h e d e p a r t m e n t i n terms o f t h e n a t u r e , d u r a t i o n and s e v e r i t y o f p a t i e n t s ' m e d i c a l c o m p l a i n t s . I t i s o f i n t e r e s t to know whether v a r i a t i o n s i n t h e p a t i e n t o m i x o c c u r d u r i n g d i f f e r e n t t i m e p e r i o d s , t o d e t e r m i n e i f s t a f f i n g a r r a n g e -ments must be a l t e r e d i f o p t i o n a l c a r e i s t o be p r o v i d e d . As shown i n T a b l e 5.2, o n l y 11.51 p e r c e n t o f t h e sampled p a t i e n t s a r r i v e d d u r i n g t h e n i g h t t i m e h o u r s ( m i d n i g h t t o 7:59 a.m.). A l t h o u g h more of t h e sampled p a t i e n t s a r r i v e d d u r i n g t h e e v e n i n g h o u r £ ( 4 : 0 0 p.m. t o 11:59 p.m.) t h a n t h e day h o u r s (8:00 a.m. t o 3:59 p.m.), t h e w o r k l o a d o f t h e day h o u r s i s i n c r e a s e d c o n s i d e r a b l y by p a t i e n t s w i t h s c h e d u l e d a p p o i n t -ments . 95 TABLE 5.1 FREQUENCY DISTRIBUTION OF PATIENTS BY TIME OF EMERGENCY DEPARTMENT V I S I T : DAY OF THE WEEK AND HOUR OF THE DAY  HOUR OF THE DAY DAY OF THE WEEK Monday Tuesday Wednesday Thur sday F r i d a y S a t u r d a y Sunday T o t a l MIDNIGHT -7:59 AM 3 8 5 7 9 8 8 48 8:00 AM •3:59 PM 24 22 23 9 21 29 36 164 4:00 PM •11:59 PM 27 26 30 33 27 31 31 205 TOTAL 54 56 58 49 57 68 75 417 No t e : T h i s t a b l e e x c l u d e s f i v e p a t i e n t s f o r whom t i m e o f v i s i t i s n o t known. TABLE 5.2 PERCENTAGE DISTRIBUTION OF PATIENTS WITHIN EACH DAY OF THE WEEK CATEGORY BY HOUR OE EMERGENCY DEPARTMENT V I S I T HOUR OF THE DAY DAY OF MIDNIGHT 8:00 AM 4:00 PM THE WEEK NUMBER TOTAL -7:59 AM -3:59 PM -11:59 PM Monday 54 100% 5 . 56 44 . .44 50 . , 00 Tue s d a y 56 100% 14 . 29 39 . , 29 46 . .43 Wednesday 58 100% 8 . 62 39 . . 66 51 . .72 Thur sday 49 100% 14 . 29 18 . .37 67 . 35 F r i d a y 57 100% 15 . 79 36 . .84 47 . .37 S a t u r d a y 68 100% 11 . 76 42 . . 65 45 . . 59 Sunday 75 100% 10 . 67 48 . . 00 41 , .33 T o t a l 417 100% 11 . 51 39 . . 33 49 . 16 Note : T h i s t a b l e e x c l u d e s f i v e p a t i e n t s f o r whom t i m e o f v i s i t i s n o t known. 96 C r o s s t a b u l a t i o n s were p e r f r o m e d t o d e t e r m i n e whether t h e n a t u r e o f t h e demand f o r emergency d e p a r t m e n t s e r v i c e s v a r i e s d u r i n g t h e d i f f e r e n t t i m e p e r i o d s u nder c o n s i d e r a t i o n . A v e r y s u r p r i s i n g f i n d i n g was t h e l a c k o f s i g n i f i c a n t d i f f e r e n c e s i n p a t i e n t - r e p o r t e d u r g e n c y o f c o m p l a i n t s among p a t i e n t s a r r i v i n g a t d i f f e r e n t t i m e p e r i o d s . As e x p e c t e d , t h e l o w e s t p r o p o r t i o n o f n o n u r g e n t p a t i e n t s a r r i v e d d u r i n g t h e n i g h t t i m e h o u r s ; however, even d u r i n g t h i s t i m e p e r i o d , a l m o s t a t h i r d o f t h e p a t i e n t s p e r c e i v e d t h e i r c o n d i t i o n s t o be n o n u r g e n t ( T a b l e 5 . 3 ) . TABLE 5.3 PERCENTAGE DISTRIBUTION OF PATIENTS WITHIN EACH HOUR OF THE DAY CATEGORY BY PATIENTS' ASSESSMENT OF URGENCY OF PRESENTING COMPLAINT PATIENTS' ASSESSMENT OF URGENCY U r g e n t N o n u r g e n t MIDNIGHT -7 : 59 AM 68 .75 31.25 P e r c e n t a g e 100% Number 48 HOUR OF THE DAY 8:00 AM -3:59 PM 55.41 44.59 100% 157 4:00 PM -11:59 PM 62.50 37 .50 100% 200 TOTAL 6 0 . 4 '9 39.51 100% 405 A n o t h e r u n e x p e c t e d f i n d i n g was t h e l a c k o f s i g n i f i c a n t d i f f e r e n c e s i n d u r a t i o n o f c o m p l a i n t s among p a t i e n t s a r r i v i n g a t d i f f e r e n t t i m e p e r i o d s . I t was e x p e c t e d t h a t t h e s m a l l e s t p r o p o r t i o n o f p a t i e n t s w i t h " o l d " c o m p l a i n t s would a r r i v e d u r i n g t h e n i g h t t i m e h o u r s . In a c t u a l f a c t , however, t h e h i g h e s t p r o -p o r t i o n o f p a t i e n t s who r e p o r t e d d u r a t i o n s o f more t h a n 24 h o u r s 97 a r r i v e d d u r i n g t h e m i d n i g h t t o 7:59 a.m. t i m e p e r i o d , a l t h o u g h t h e d i f f e r e n c e i s n o t s t a t i s t i c a l l y s i g n i f i c a n t ( T a b l e 5 . 4 ) . T A B L E 5.4 P E R C E N T A G E D I S T R I B U T I O N OF P A T I E N T S W I T H I N EACH HOUR OF THE DAY CATEGORY BY DURATION OF P R E S E N T I N G C O M P L A I N T S HOUR OF THE DAY DURATION M I D N I G H T 8:00 AM 4:00 PM OF C O M P L A I N T - 7 : 5 9 AM - 3 : 5 9 PM - 1 1 : 5 9 PM TOTAL 24 H o u r s o r L e s s 7 2 . 9 2 7 7 . 7 8 8 2 . 5 9 7 9 . 5 6 M o r e T h a n 24 H o u r s 2 7 . 0 8 2 2 . 2 2 1 7 . 4 1 2 0 . 4 4 T o t a l P e r c e n t a g e 1 0 0 % 1 0 0 % 1 0 0 % 1 0 0 % N u m b e r 48 162 2 0 1 4 1 1 On t h e o t h e r h a n d , a s i g n i f i c a n t r e l a t i o n s h i p ( a t t h e .001 l e v e l o f c o n f i d e n c e ) d o e s e x i s t b e t w e e n h o u r o f v i s i t a n d n a t u r e o f p r e s e n t i n g c o m p l a i n t . C o m p a r e d t o t h e d a y a n d e v e n i n g h o u r s , a s i g n i f i c a n t l y h i g h e r p r o p o r t i o n o f p a t i e n t s s u f f e r i n g f r o m a n i l l n e s s a r r i v e d d u r i n g t h e n i g h t t i m e h o u r s ( T a b l e 5 . 5 ) . F u r t h e r a n a l y s e s , h o w e v e r , r e v e a l e d t h a t t h e r e l a t i o n s h i p b e t w e e n h o u r o f v i s i t a n d n a t u r e o f c o m p l a i n t i s o n l y s i g n i f i c a n t f o r t h e d a y s M o n d a y t h r o u g h F r i d a y ( a t t h e .001 l e v e l o f c o n f i d e n c e ) ( T a b l e 5 . 6 ) . On S a t u r d a y a n d S u n d a y , t h e l a r g e s t p e r c e n t a g e o f p a t i e n t s w i t h i l l n e s s e s a r r i v e d d u r i n g t h e e v e n i n g h o u r s , a l -t h o u g h t h e d i f f e r e n c e i s n o t s t a t i s t i c a l l y s i g n i f i c a n t ( T a b l e 5 . 7 ) . 98 T A B L E 5.5 P E R C E N T A G E D I S T R I B U T I O N OF P A T I E N T S W I T H I N EACH HOUR OF THE DAY CATEGORY BY NATURE OF P R E S E N T I N G C O M P L A I N T  HOUR OF THE DAY NATURE OF C O M P L A I N T I n j u r y I l i n e s s MI D N I G H T - 7 : 5 9 AM 51 . 06 48 . 94 T o t a l P e r c e n t a g e N u m b e r 1 0 0 % 47 8:00 AM •3:59 PM 78 . 05 2 1 . 9 5 1 0 0 % 164 4:00 PM - 1 1 : 5 9 PM 77 . 94 22 . 06 1 0 0 % 204 T O TAL 74 . 94 25 . 06 1 0 0 % 4 1 5 T A B L E 5.6 P E R C E N T A G E D I S T R I B U T I O N OF P A T I E N T S W I T H I N EACH HOUR OF THE DAY CATEGORY (MONDAY TO F R I D A Y ) BY NATURE OF P R E S E N T I N G C O M P L A I N T  MONDAY TO F R I D A Y NATURE OF C O M P L A I N T M I D N I G H T - 7 : 5 9 AM 8:00 AM •3:59 PM 4:00 PM •11:59 PM TOTAL I n j u r y I l l n e s s T o t a l 4 1 . 9 4 58 . 06 P e r c e n t a g e 1 0 0 % N u m b e r 31 80 .81 1 9 . 1 9 1 0 0 % 99 8 3 . 1 0 16 . 90 1 0 0 % 142 7 7 . 5 7 2 2 . 4 3 1 0 0 % 272 T A B L E 5.7 P E R C E N T A G E D I S T R I B U T I O N OF P A T I E N T S W I T H I N EACH HOUR OF THE DAY CATEGORY (SATURDAY & SUNDAY) BY NATURE OF P R E S E N T I N G C O M P L A I N T SATURDAY & SUNDAY NATURE OF C O M P L A I N T I n j u r y I l l n e s s T o t a l M I D N I G H T - 7 : 5 9 AM 6 8 . 7 5 3 1 . 2 5 P e r c e n t a g e N u m b e r 1 0 0 % 16 8:00 AM •3:59 PM 73 .85 2 6 . 1 5 1 0 0 % 65 4:00 PM - 1 1 : 5 9 PM 66 . 13 33 .87 1 0 0 % 62 TOTAL 69 . 93 3 0.07. 1 0 0 % 1 4 3 99 In summary, t h e p a t i e n t mix o f L i o n s G a t e ' s emergency d e p a r t m e n t i s n o t s t r o n g l y a s s o c i a t e d w i t h t i m e o f v i s i t . P a t i e n t s a r e as l i k e l y t o use t h e emergency d e p a r t m e n t f o r non-u r g e n t c o n d i t i o n s d u r i n g t h e n i g h t t i m e h o u r s as t h e y a r e d u r i n g t h e day and e v e n i n g h o u r s . The same p a t t e r n i s t r u e f o r " o l d " c o m p l a i n t s . O n l y t h e n a t u r e o f t h e p a t i e n t s ' c o m p l a i n t s was f o u n d t o be s t a t i s t i c a l l y a s s o c i a t e d w i t h hour o f v i s i t , and even h e r e , t h e r e l a t i o n s h i p i s o n l y s i g n i f i c a n t f o r t h e days Monday t h r o u g h F r i d a y . A l t h o u g h fewer s t a f f a r e r e q u i r e d d u r i n g t h e n i g h t t i m e h o u r s , s t a f f must s t i l l be p r e p a r e d t o p r o v i d e p r i m a r y m e d i c a l c a r e as w e l l as a c u t e emergency c a r e d u r i n g t h e m i d n i g h t t o 7:59 a.m. t i m e p e r i o d . On t h e b a s i s o f t h e r e s u l t s o f t h i s s t u d y , i t was recom-mended t h a t f u t u r e p l a n s f o r e i t h e r t h e m o d i f i c a t i o n o r expan-s i o n o f L i o n s G a t e ' s emergency d e p a r t m e n t s h o u l d i n c l u d e t h e e s t a b l i s h m e n t w i t h i n t h e d e p a r t m e n t o f a p r i m a r y c a r e c l i n i c . O b v i o u s l y , t h e s t a f f i n g o f t h e p r o p o s e d a m b u l a t o r y c a r e d e p a r t -ment s h o u l d be b a s e d on a d e t a i l e d h o u r l y w o r k l o a d a n a l y s i s o f t h e d e p a r t m e n t . However, i f t h e l i g h t w o r k l o a d o f t h e emer-gency d e p a r t m e n t d u r i n g t h e n i g h t t i m e h o u r s c o n t i n u e s , i t seems r e a s o n a b l e t o s u g g e s t t h a t t h e p r o p o s e d p r i m a r y c a r e c l i n i c c o u l d be c l o s e d d u r i n g t h e m i d n i g h t t o 7:59 a.m. t i m e p e r i o d , as l o n g as t h e s t a f f o f t h e emergency c e n t r e a r e p r e -p a r e d t o p r o v i d e p r i m a r y m e d i c a l c a r e d u r i n g t h e s e h o u r s . 100 A p p e n d i x 6 S o c i o e c o n o m i c C h a r a c t e r i s t i c s o f t h e Emergency Department P a t i e n t s D a t a were c o l l e c t e d i n r e g a r d t o v a r i o u s s o c i o e c o n o m i c c h a r a c t e r i e s t i c s o f t h e p a t i e n t s ; and, f o r c o m p a r a t i v e p u r p o s e s , s i m i l a r d a t a were g a t h e r e d f r o m t h e 1971 Census i n r e g a r d t o t h e g e n e r a l p o p u l a t i o n r e s i d i n g on t h e N o r t h S h o r e . —" E i g h t e e n o f t h e sampled p a t i e n t s r e s i d e o u t s i d e t h e m e t r o p o l i t a n V a n c o u v e r a r e a ; t h e s e p a t i e n t s were e x c l u d e d f r o m t h i s p o r t i o n o f t h e s t u d y , l e a v i n g a sample o f 404 p a t i e n t s (95.73 p e r c e n t o f t h e t o t a l s a m p l e ) . P r e v i o u s s t u d i e s have d e t e r m i n e d t h a t a p p r o x i m a t e l y 95 p e r c e n t o f emergency d e p a r t m e n t p a t i e n t s a t L i o n s Gate H o s p i t a l r e s i d e on t h e N o r t h Shore (Emergency M e d i c a l S e r v i c e s Sub-Committee, 1970); c o n s e q u e n t l y , i t was assumed t h a t p a t i e n t s who s t a t e d t h a t t h e y l i v e i n t h e m e t r o p o l i t a n V a n c o u v e r a r e a a c t u a l l y r e s i d e on t h e N o r t h S h o r e . A l t h o u g h e x p l o r a t o r y i n n a t u r e , t h e p r e s e n t a n a l y s i s w i l l h e l p d e t e r m i n e whether t h e usage o f t h e emergency d e p a r t m e n t i s t h e same f o r a l l segments o f t h e p o p u l a t i o n , o r whether d i f f e r -e n t i a l use by segments o f t h e p o p u l a t i o n e x i s t s . I f t h e l a t t e r 1_. C o m p a r i s o n s between p a t i e n t s and t h e g e n e r a l p o p u l a t i o n were not made r e g a r d i n g e d u c a t i o n a l l e v e l , o c c u p a t i o n a l s t a t u s , and f a m i l y income, e i t h e r b e c a u s e t h e d a t a were n o t c o m p a t i b l e o r b e c a u s e i t was f e l t t h a t t h e 1971 Census d a t a was o u t d a t e d a t t h e t i m e o f t h e s t u d y . 101 i s t r u e , t h e n a s h i f t i n t h e c o m p o s i t i o n o f t h e p o p u l a t i o n i n t h e s e r v i c e a r e a o f L i o n s Gate H o s p i t a l w i l l a l e r t t h e h o s p i t a l ' s a d m i n i s t r a t o r s t o t h e need t o a s s e s s t h e e f f e c t s o f t h e s e c h a n g es on t h e u t i l i z a t i o n p a t t e r n s o f t h e h o s p i t a l ' s emergency d e p a r t -ment. In a d d i t i o n , however, t h e m a t t e r o f r e l a t i n g d i f f e r e n c e s i n usage t o b a s i c p o p u l a t i o n c h a r a c t e r i s t i c s w i l l e n a b l e t h o s e r e s p o n s i b l e f o r p l a n n i n g t h e f u t u r e o f t h e emergency d e p a r t m e n t t o move beyond t h e p r a c t i c e o f r e a c t i n g t o u t i l i z a t i o n c hanges a f t e r t h e e v e n t t o p l a n n i n g f o r f u t u r e c h a n g es ( G i b s o n , 1973 c ) . I f d i f f e r e n t i a l usage by segments o f t h e p o p u l a t i o n e x i s t s , t h e n p o p u l a t i o n f o r e c a s t s become u s e f u l t o o l s f o r h e a l t h c a r e p l a n n e r s P r e d i c t e d s h i f t s i n t h e c o m p o s i t i o n o f t h e p o p u l a t i o n i n t h e h o s p i t a l ' s s e r v i c e a r e a w i l l e n a b l e p l a n n e r s t o a n t i c i p a t e t h e e f f e c t s o f t h e s e c h a n g es on t h e f u n c t i o n s or r o l e s p e r f o r m e d by t h e emergency d e p a r t m e n t . Emergency d e p a r t m e n t p a t i e n t s i n some a r e a s o f t h e U n i t e d S t a t e s have been f o u n d t o come from f a m i l i e s c h a r a c t e r i z e d by h i g h r a t e s o f unemployment, and low f a m i l y incomes (Weinerman, R a t n e r , R o b b i n s & L a v e n h a r , 1966). Such i s n o t t h e c a s e i n r e g a r d t o o u r sample o f p a t i e n t s . F a m i l y heads o f L i o n s G a t e ' s emergency d e p a r t m e n t p a t i e n t s have r e l a t i v e l y h i g h l e v e l s o f e d u c a t i o n , and few a r e unemployed. F a m i l y incomes t e n d t o be f a i r l y h i g h , w i t h a l m o s t h a l f o f t h e f a m i l i e s h a v i n g t o t a l i ncomes i n 1973 o f $15,000 and o v e r ( T a b l e 6.1). 102 TABLE 6.1 DISTRIBUTION OF PATIENTS BY FAMILY CHARACTERISTICS FAMILY CHARACTERISTICS EDUCATIONAL LEVEL OF FAMILY HEAD L e s s Than Grade 9 Gra d e s 9 - 1 1 Grades 12 - 13 Some U n i v e r s i t y U n i v e r s i t y Degree T o t a l PATIENTS NUMBER 23 84 126 66 93 392 PERCENTAGE 5.87 21.43 32 .14 16 .84 23.72 100% OCCUPATIONAL STATUS OF FAMILY HEAD Employed F u l l Time Employed P a r t Time Unemployed H o u s e w i f e S t u d e n t R e t i r e d T o t a l 335 18 8 8 9 18 396 84 . 60 4.55 2 . 02 2 . 02 2.27 4 .55 100% FAMILY INCOME (1973) L e s s Than $3,000 $3,000 - $4,999 $5,000 - $6,999 $7,000 - $9,999 $10,000 - $14,999 $15,000 and Over 12 23 22 40 94 165 3.37 6.46 6 . 18 11 .24 26.40 46.35 T o t a l 356 100% 103 In terms o f p r o p o r t i o n a l r e p r e s e n t a t i o n , m a l e s , t h e young and t h e s i n g l e a r e o v e r r e p r e s e n t e d among t h e emergency d e p a r t -ment p a t i e n t s ( T a b l e 6.2). The sample o f p a t i e n t s c o n t a i n s 62.72 p e r c e n t o f males i n c o m p a r i s o n w i t h 49.27 p e r c e n t f o r t h e g e n e r a l p o p u l a t i o n . In a d d i t i o n , t h e d a t a i n d i c a t e t h a t t h e p a t i e n t s a r e y o u n g e r t h a n t h e g e n e r a l p o p u l a t i o n , w i t h h i g h p r o p o r t i o n s o f p a t i e n t s i n t h e 5 - 2 4 y e a r s o f age c a t e g o r y . O b v i o u s l y , age and m a r i t a l s t a t u s a r e i n t e r r e l a t e d ; t h u s , i t i s n o t s u r p r i s i n g t h a t s i n g l e p e o p l e a r e a l s o o v e r r e p r e s e n t e d among t h e emergency d e p a r t m e n t p a t i e n t s . As shown i n t h e c o n t i n u a n c e o f T a b l e 6.2, t h o s e b o r n i n Canada and t h o s e o f n o n - B r i t i s h a n c e s t r y a r e o v e r r e p r e s e n t e d among t h e emergency d e p a r t m e n t p a t i e n t s , a l t h o u g h C a n a d i a n -b o r n p a t i e n t s o n l y s l i g h t l y e x c e e d t h e i r d i s t r i b u t i o n i n t h e g e n e r a l p o p u l a t i o n . L a r g e r d i f f e r e n c e s o c c u r , however, when e t h n i c o r i g i n i s examined. P a t i e n t s o f n o n - B r i t i s h a n c e s t r y e x c e e d t h e i r d i s t r i b u t i o n i n t h e g e n e r a l p o p u l a t i o n by more t h a n t e n p e r c e n t . F i n a l l y , t h e d a t a i n d i c a t e t h a t emergency d e p a r t m e n t p a t i e n t s come from f a m i l i e s w i t h s l i g h t l y s h o r t e r t e n u r e o f r e s i d e n c e t h a n t h o s e i n t h e g e n e r a l p o p u l a t i o n ; 26.08 p e r c e n t o f heads o f f a m i l i e s o f p a t i e n t s have r e s i d e d a t t h e i r p r e s e n t a d d r e s s f o r l e s s t h a n one y e a r compared t o 21.27 p e r c e n t o f heads o f h o u s e h o l d s on t h e N o r t h S h o r e . 104 TABLE 6.2 SOCIOCULTURAL CHARACTERISTICS OF THE EMERGENCY DEPARTMENT PATIENTS AND THE POPULATION OF THE NORTH SHORE SOCIOCULTURAL CHARACTERISTICS SEX DISTRIBUTION Male Female T o t a l P e r c e n t a g e Number EMERGENCY DEPARTMENT PATIENTS 62.72% 37.28 100% 397 NORTH SHORE POPULATION 49.27% 50.73 100% 126,155 AGE DISTRIBUTION 0 - 4 Y e a r s 5 - 1 4 Y e a r s 15 - 24 Y e a r s 25 - 44 Y e a r s 45 S 1 6 4 Y e a r s 65 Y e a r s o r Over T o t a l P e r c e n t a g e Number 7 .05% 27.20 26 . 70 23.43 12.59 3.02 100% 397 7.21% 19.83 16 . 82 26.97. 21.79 7.37 100% 126,155 MARITAL STATUS S i n g l e , Under 15 Y e a r s S i n g l e , 15 Y e a r s o r Over M a r r i e d Widowed, D i v o r c e d o r S e p a r a t e d T o t a l P e r c e n t a g e Number 34.26% 28.21 30.98 6 .55 100% 397 27.05% 17 . 06 48.27 7 . 62 100% 126,160 105 TABLE 6.2 ( C o n t i n u e d ) SOCIOCULTURAL CHARACTERISTICS OF THE EMERGENCY DEPARTMENT PATIENTS AND THE POPULATION OF THE NORTH SHORE SOCIOCULTURAL CHARACTERISTICS BIRTHPLACE Born i n Canada Born O u t s i d e Canada T o t a l P e r c e n t a g e Number EMERGENCY DEPARTMENT PATIENTS 78 .43% 21.57 100% 394 NORTH SHORE POPULATION 74.58% 2 5.42 100% 126,260 ETHNIC GROUP B r i t i s h I s l e s F r e n c h German S c a n d i n a v i a n O t h e r T o t a l P e r c e n t a g e Number 60.92% 3 . 74 8.33 8 .05 18.97 100% 348 71.48% 2.51 6 .62 4 . 69 14.70 100% 126,260 LENGTH OF TIME AT PRESENT ADDRESS * L e s s Than One Y e a r 1 - 2 Y e a r s 3 - 5 Y e a r s 6 -•• 10 Y e a r s More Than 10 Y e a r s T o t a l P e r c e n t a g e Number 26.08% 19.75 17.72 17.22 19 .24 100% 395 (f a m i l i e s) 21.27% 16 . 78 17.57 18.04 26.35 100% 38,865 ( h o u s e h o l d s ) * F o r t h e emergency d e p a r t m e n t p a t i e n t s , t h e d a t a r e f e r t o t h e l e n g t h o f t i m e t h e head o f t h e f a m i l y has o c c u p i e d t h e d w e l l i n g , whereas f o r t h e N o r t h Shore p o p u l a t i o n , t h e c e n s u s d a t a r e f e r t o t h e l e n g t h o f t i m e t h e head o f t h e h o u s e h o l d has o c c u p i e d t h e d w e l l i n g . A h o u s e h o l d u s u a l l y c o n s i s t s o f one f a m i l y , a l t h o u g h i t may c o n s i s t o f o t h e r g r o u p s , s u c h as two or more f a m i l i e s s h a r i n g a d w e l l i n g . 106 The p o p u l a t i o n u t i l i z i n g L i o n s G a t e ' s emergency d e p a r t -ment can be c o n t r a s t e d w i t h t h e g e n e r a l p o p u l a t i o n as b e i n g male, young, s i n g l e , and o f n o n - B r i t i s h a n c e s t r y . The p a t i e n t g r o u p i s a l s o s l i g h t l y more l i k e l y t h a n t h e t o t a l p o p u l a t i o n t o have been b o r n i n Canada, and t o have l i v e d f o r a s h o r t e r p e r i o d o f t i m e a t t h e i r p r e s e n t a d d r e s s . The p r e d i c t i o n o f emergency d e p a r t m e n t u t i l i z a t i o n f r o m a knowledge o f p o p u l a t i o n c h a r a c t e r -i s t i c s has been d e s c r i b e d as "... one o f t h e most i m p o r t a n t p r i o r i t i e s i n c o n t e m p o r a r y a m b u l a t o r y h e a l t h c a r e p l a n n i n g ( G i b s o n , 1973c, p . 1 0 5 ) . " The p r e s e n t a n a l y s i s has been e x p l o r a -t o r y i n n a t u r e , however, and f u r t h e r r e s e a r c h i s r e q u i r e d b e f o r e t h e complex r e l a t i o n s h i p between s o c i o e c o n o m i c c h a r a c t e r i s t i c s and emergency d e p a r t m e n t u t i l i z a t i o n w i l l be u n d e r s t o o d . The need f o r a d d i t i o n a l a n a l y s i s i s o b v i o u s , b o t h i n d e t e r m i n i n g t h e r e l a t i v e i m p o r t a n c e o f t h e d i f f e r e n t s o c i o e c o n o m i c c h a r a c t e r i s -t i c s i n / i n f l u e n c i n g t h e demand f o r emergency s e r v i c e s , and i n d e t e r m i n i n g t h e r e l a t i v e i n f l u e n c e o f v a r i o u s i n t e r v e n i n g v a r i a b l e s , s u c h as t h e a b s e n c e o f a l t e r n a t i v e s o u r c e s o f ambu-l a t o r y c a r e . 

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