Table of Contents  

Yousuf, Saad, Mulla, and Hassan: Extending the opening hours of family medicine clinics will reduce load on emergency departments – effects on the early detection of limb fractures

Introduction

Family physicians, often known as primary care physicians, are qualified to provide essential health care for all ages and for most ailments.1 The usual opening hours of any functioning clinic within a hospital are during the day. Once these clinics are closed, patients with both serious and non-serious complaints are diverted to emergency departments (EDs), which can lead to ED crowding: one study has reported that as many as 55.4% of all cases in EDs are non-urgent.2 This situation has been regularly reported for EDs in the United States, which frequently function at or over 100% capacity.3 Musculoskeletal injuries account for about 50% of presentations to ED,4 among which trauma-related fractures, which can lead to morbidity, mortality and compromised quality of life, including increased medical costs and lasting disabilities, are relatively common.5,6 In recent studies, the annual incidence of hospitalization as a result of injury has ranged from 65 to 136 per 100 000.7,8 The incidence of trauma-related death in the United Arab Emirates (UAE) is 7.4 per 100 000.9 Hence, it is very important that patients are diagnosed both promptly and efficiently. At night, when clinics are closed, patients with limb complaints, including patients with limb trauma, present at EDs for acute management. The consequences for these patients include unreasonably extended waiting times due to their comparatively low priority.

The UAE is a fast-developing country with a population of more than 6 million. Until recently, in the south of Dubai a 24-hour government emergency facility was provided only by hospitals more than 30 km from Al-Barsha Health Center. Al-Barsha Health Center plays an important role in medical care for the local community and expatriates, serving a population of over 60 000 residing in and around the Al-Barsha area. As a result of its location and the high demand for its medical services, Al-Barsha Health Center was converted from a regular clinic to a 24-hour clinic in September 2013. This was necessary to reduce the burden of patients presenting to the ED (where family physicians were available 24 hours to deal with emergency and non-emergency cases), which had led to an increased mortality rate among hospital inpatients. Furthermore, an overcrowded ED makes it more likely that patients will leave against medical advice or without being seen at all (13–20%).10,11 The situation is at its worst at night, when the proportion of patients leaving the ED because of crowding and without being seen at all is double that during the day.10 Hence, it seems that a night-time clinical service, which could be available as an ambulatory service, would be an effective way to reduce ED crowding. Therefore, it can be speculated that extending family medicine (FM) clinics’ opening hours to 24 hours will both indirectly reduce the burden on EDs and increase patient satisfaction.

Understanding the benefits of extending the opening hours of a health centre is necessary in order to present evidence-based recommendations for the improvement of treatment facilities and future medical services. We sought to identify the impact of increasing FM clinic opening hours from regular to extended hours on the detection of limb fractures. To achieve this aim, we compared the frequency of limb complaints and fractures during regular hours and extended hours. The relationship between fracture positivity, number of patients handled by the FM clinic and number patients referred by the FM clinic to another department was also investigated. Additionally, the site of injury (upper or lower limb) and its association with fracture positivity and patient referral were compared for both regular and extended hours.

Materials and methods

A cross-sectional comparative study was carried out at Al-Barsha Health Center in Dubai, UAE. The opening hours of the clinic were categorized as regular hours (7:30–21:30 hours) and extended hours (21:30–7:30 hours). Data were compiled over a 3-month period from the date of ethics review committee approval (DSREC-07/2015_04): 1 January 2015 to 31 March 2015. Data were included for patients who underwent limb radiography at Al-Barsha Health Center during that period.

All registered Al-Barsha Health Center patients undergoing limb radiography during the period of study were included; patients undergoing limb radiography outside Al-Barsha Health Center were excluded. A list of all limb radiography that was carried out at Al-Barsha Health Center during the period of study was compiled by the investigator from medical records. All data were confidential and no personal information was shared with unauthorized parties.

Data on the influx of patients and diagnoses of fractures during the same 3 months (1 January 2015 to 31 March) of 2013, when regular clinics were operational but extended opening hours had not been introduced, were collected by the same means and compared with the 2015 data.

Demographic data for all study participants were documented, including age, sex and nationality.

The total number of patients was recorded, and patients were categorized by time of attendance: during regular hours or extended hours. Fracture positivity in all patients – patients who attended during regular hours and patients who attended during extended hours – was documented. The number of patients handled by the FM clinic and the number of patients referred by the FM clinic to the ED or another department was documented for all patients. Site of injury, sick leave and time of radiography were also documented for all patients.

Fractures were diagnosed by radiography. Descriptive statistics, frequencies and proportions were calculated for categorical variables such as sex, site of fracture, referral and sick leave. Mean and standard deviations were calculated for age. SPSS Statistics version 24 (IBM Corporation, Armonk, NY, USA) was used for analysis; chi-squared tests were used to determine association and P-values < 0.05 were considered significant.

Results

A total of 736 patients were studied between 1 January 2015 and 31 March 2015. A total of 59.1% (435) were male and 40.9% (301) were female, with a mean age of 27.77 ± 18.34 years, indicating no significant difference between the total number of male and female patients. A total of 86.1% (634) were nationals and 13.9% (102) were non-nationals. The mean age of patients who attended during regular and extended hours was 29.26 ± 19.05 years and 23.41 ± 15.09 years, respectively.

Of all 736 patients who attended the FM clinic, 81.79% (602) attended during regular hours and 18.21% (134) attended during extended hours. Comparing the number of male and female patients who attended during regular and extended hours, the majority of patients who attended during extended hours were male (71.7%, 96 of 134; P < 0.001). However, there was no significant difference during regular hours, when 56.3% (339 of 602) were male and 43.7% (263 of 602) were female.

When the presence of fracture was assessed, we found that 14.7% (108) of the total of 736 patients were fracture positive and 85.3% (628) were fracture negative, as shown in Table 1.

TABLE 1

Management of patients with limb complaints during regular vs. extended hours

Regular hours, n (%) Extended hours, n (%) Total number
Number of patients undergoing radiography 602 (81.79) 134 (18.21) 736
 Male 339/602 (56.30) 96/134 (71.70) 435
 Female 263/602 (43.70) 38/134 (28.30) 301
Patients handled by the FM clinic 452/602 (75.10) 104/134 (77.60) 556
Patients referred to the ED or another department 150/602 (24.91) 30/134 (22.30) 180
Fracture-positive patients 85/602(14.11) 23/134 (17.16) 108
 Handled by the FM clinic 34/85 (40.00) 9/23 (39.13) 43
 Referred to the ED or another department 51/85 (60.00) 14/23 (60.86) 65

Of the patients who attended during regular hours (602), 14.11% (85) were fracture positive. Of the patients who attended during extended hours (134), 17.16% (23) were fracture positive. Though more patients were fracture positive during extended hours, this difference was not statistically significant.

The frequency of fracture positivity in male and female patients was determined. Of the 435 male patients across both regular and extended hours, 17.5% (76) were fracture positive. Of the 301 female patients across both regular and extended hours, 10.6% (32) were fracture positive. Overall, more males were diagnosed with fractures than females (P < 0.05).

Of the total number of patients (736) who presented to the FM clinic, 75.6% (556) were handled by the FM clinic and 24.4% (180) were referred to the ED or another department: 95 (12.9%) patients were referred to the ED and 85 (11.5%) patients were referred to another department. Significantly more patients were handled by the FM clinic than were referred to the ED or another department (P < 0.05).

Of the 602 patients who attended during regular hours, 24.91% (150) were referred to the ED or another department and 75.1% (452) were not. In comparison, of the 134 patients who attended during extended hours, 22.3% (30) were referred and 77.6% (104) were not. Referrals were made when patients – fracture positive or fracture negative – required intervention that was beyond the scope of the FM clinic. Though more patients were referred to the ED or another department during regular hours, this difference was not statistically significant (P > 0.05).

There were significantly more referrals to the ED than to other departments (P < 0.05).

The data for referrals were further evaluated against fracture positivity: 60.2% (65 of 108) of fracture-positive patients were referred and 39.8% (43 of 108) of fracture-positive patients were not.

Referral by the FM clinic for fracture-positive patients was not affected by time of attendance (regular or extended hours) (P > 0.05). There was also no effect (P > 0.05) of the site of injury on referral.

Additionally, history of trauma was assessed: 66.98% (493 of 736) of patients had a history of trauma (P < 0.05), 25.13% (185 of 736) of patients did not; trauma history was not documented for 7.88% (58 of 736) of patients.

Patients presenting with a history of trauma had a higher chance of fracture positivity than patients with no history of trauma (96.29%, P < 0.01), as elaborated in Table 2. The chance of fracture positivity was higher for patients with a history of trauma in both regular hours (P < 0.05) and extended hours (P < 0.05).

TABLE 2

History of trauma and fracture positivity

Fracture History of trauma
Yes, n (%) No, n (%) Unknown, n (%) Total
Positive 104 (96.29) 3 (2.7) 1 (0.92) 108
Negative 389 (61.9) 182 (28.98) 57 (9.07) 628
Total 493 (66.98) 185 (25.13) 58 (7.88) 736

Assessment of the number of patients on sick leave showed that only 21.2% (156 of 736) of patients were on sick leave. The distribution of fracture positivity and sick leave is shown in Table 3.

TABLE 3

Fractures and sick leave

Fracture Sick leave
Yes, n (%) No, n (%) Total
Positive 18 (16.66) 90 (83.33) 108
Negative 138 (21.97) 490 (78.02) 628

There was no association between fracture positivity and sick leave (P > 0.05), nor between patient sex and sick leave (P > 0.0), among either fracture-positive or -negative patients. The taking of sick leave was also not affected by time of attendance (regular or extended hours). Of the fracture-positive patients who attended during regular hours (85 of 108), 22.35% were on sick leave and 77.65% were not. Similar results were found for patients who attended during extended hours: of the fracture-positive patients who attended during extended hours (23 of 108), 21.74% (5 of 23) were on sick leave and 78.6% (18 of 23) were not. The number of fracture-positive patients who attended during extended hours was not affected by sick leave (P > 0.05).

The mean number of days taken to provide a radiography report was 1.32 ± 0.273 overall: 1.28 ± 1.87 days for patients who attended during regular hours and 1.32 ± 2.28 days for patients who attended during extended hours. The number of days taken to provide a radiography report was not affected by time of attendance.

The number of days taken to provide a radiography report was not affected by fracture positivity (P > 0.05).

The majority of patients (67.4%) received their radiography report within 1 day. The number of days taken to provide a radiography report ranged from 1 to 17.

Upper limb complaints were more common than lower limb complaints [412 of 736 (55.97%) vs. 315 of 736 (42.79%), respectively] and some patients (1.22%, 9 of 736) had both upper and lower limb complaints.

More patients with upper limb complaints were fracture positive (52.8%, 57 of 108) than patients with lower limb complaints (47.2%, 51 of 108), though this difference was not statistically significant.

Of all fracture-positive patients (108), 57 had upper limb fractures. Of these, 21 patients were handled by the FM clinic, 31 patients were referred to ED and five patients were referred to another department.

The FM clinic’s opening hours in 2013 were 7.30–21.30 hours; however, radiography was unavailable from 14.00 hours. The details of patients with limb complaints who attended the FM clinic in 2013 are given in Table 4.

TABLE 4

Comparison of 2013 and 2015 data

Variable Number of patients, n (%)
2013 2015
Sex Male 42 (53.84) 435 (59.1)
Female 36 (46.15) 301 (40.9)
Nationality Local 77 (98.71) 634 (86.1)
Other 01 (1.28) 102 (13.9)
History of trauma Yes 41 (52.56) 185 (25.1)
No 18 (23.07) 493 (67)
Unknown 19 (24.35) 58 (7.9)
Fracture positive Yes 09 (11.53) 108 (14.7)
No 69 (88.46) 628 (85.3)
Referral ED 03 (3.84) 95 (12.9)
Other department 05 (6.41) 85 (11.5)
None 70 (89.74) 556 (75.6)
Sick leave No 55 (70.51) 580 (78.8)
Yes 23 (29.48) 156 (21.2)

Discussion

This study was conducted to identify the effect of increasing the opening hours of FM clinics from regular hours (7:30–21:30 hours) to extended hours (24 hours) on the early detection of limb fractures in patients with limb complaints. For this purpose, data for patients presenting during regular hours and extended hours at Al-Barsha Health Center over a 3-month period were analysed and compared.

An initial assessment of variables revealed that the number of patients who attended during extended hours was lower than the number of patients who attended during regular hours, which is understandable: patients who present during extended hours are typically those who seek urgent help and cannot wait for the next-day opening of clinics. The greater influx of male patients during extended hours is also understandable: traumatic injuries at night are typically caused by accidents, and cultural factors limit the liberty of women to wander at night-time, reducing the potential for accidents. Additionally, more patients were fracture positive during extended hours than during regular hours (17.16% vs. 14.11%), which indicates the significance of extending clinic opening hours. There were more fractures in patients presenting with upper limb complaints than lower limb complaints, but the difference was not statistically significant. This is in contrast to previous reports that the most common site of trauma-related fractures is the lower limb (41%), followed by the upper limb (29%).7,8 However, the population and study design in those studies were notably different.

To understand the significance of extended opening hours, we next considered patients referred by the FM clinic to the ED or another department to understand FM clinic capacity to diagnose and manage limb complaints. A significant number of patients were handled in the FM clinic and significantly fewer patients were referred (75.6% vs. 24.4%; P < 0.05). Of the referred patients, 12.9% were referred to the ED and 11.5% were referred to another department.

Since the aim of the study was to understand the capacity of FM clinics to manage limb complaints during extended clinic opening hours, we analysed the number of patients who were handled by the FM clinic and the number of referrals during extended hours. It was found that only 22.38% of the total patients attending the FM clinic during extended hours were referred and 77.62% were handled by the FM clinic. Thus, it can be deduced that at least 77.62% (104 of 134) of patients with limb complaints may have presented to the ED for acute management if the FM clinic had not been available, which could have led to ED crowding. Numerous studies report that ED crowding is associated with poor performance for major trauma patients,12 high rates of patients leaving the ED without being seen and poor patient outcomes.11 Furthermore, it has been shown to lead to greater mortality in both patients admitted to the hospital13 and discharged patients.12 In a population study in Canada, it was estimated that the number of deaths in EDs could be reduced in high-risk and low-risk patients by 6.5% and almost 13%, respectively, if the length of stay in the ED is decreased by merely 1 hour.14,15 Hence, extending FM clinic opening hours and handling a significant number of patients may have indirectly reduced ED crowding.

One advantage of managing patients with limb complaints at FM clinics during extended hours is reduced waiting times, ensuring more timely management. Patients with limb complaints often require acute care, and in EDs they are classified as low priority, in contrast to life-threatening cases. This is particularly significant for Al-Barsha Health Center since there are no government hospitals in a 30 km vicinity: the load of patients seeking emergency care falls on Al-Barsha Health Center’s ED.

One area that requires further investigation is the accuracy of fracture diagnosis by FM physicians. Studies report that FM physicians on a rotation of an average of 5 weeks in an orthopaedic service during their training show significantly less confidence in the management of musculoskeletal conditions than those on a rotation of 8 weeks or more.16 Earlier, a hospital set-up that adopted a rapid review process, which involved an on-call orthopaedic consultant for overnight radiography in an ED that cross-checked with reported diagnosis, proved to be very efficient in terms of both cost and patient satisfaction.17 Hence, another suggestion for improving an FM clinic’s qualitative outcomes is to recruit an on-call orthopaedic consultant/radiologist for some or all patients during the hours of closure of the clinic as a part of a rapid review process. This could significantly improve the diagnostic and management outcomes as well as play a role in training the FM clinic in diagnosing and managing limb complaints.

Another aspect of the study worth addressing is the high number of fracture-positive patients who were referred. Of the 134 patients who presented during extended hours, 23 were fracture positive. Of these, 60.8% (14 of 23) were referred and only 39.2% were handled by the FM clinic. This calls into question the benefit of FM clinics if more than 60% of fracture patients are referred. However, it is worth mentioning here that the rate of referral of fracture-positive patients was similar during both regular and extended hours, which indicates that the quality of care during extended hours is not compromised and that some complicated fractures are simply beyond the scope of FM clinics. The FM clinic of Al-Barsha Health Center has the facility to provide basic care such as dressing, stabilizing fractures with slabs and pain management. However, like other ambulatory clinics, it is not equipped to deal with complicated procedures and therefore such fracture patients are referred to the ED. Hence, it can be confidently deduced that management capacity was not compromised during extended hours: patients with fractures who were referred to the ED required ED services. By managing the majority of patients with limb complaints during extended hours, the FM clinic ensured that only patients requiring ED services reached the ED. Additionally, fracture-positive patients who are referred by the FM clinic to the ED are likely to have had their level of emergency and radiography needs assessed, and may have received some form of pain management, in cases where the injury is not life threatening. This early management of patients with limb complaints can avoid unnecessary waiting times for primary diagnosis and management.

The data for extended hours over the 3-month period showed a total of 134 patients with limb complaints arriving at the FM clinic, which means that, on average, 1–2 patients presented each night with limb complaints. Owing to the smaller number of patients with limb complaints who were handled per night, the cost of running a clinic compared with the cost avoided by the ED is called into question. It is therefore important to note that the FM clinic was catering for other complaints – serious and non-serious – in addition to limb complaints during extended hours, which could justify the cost of these extended opening hours. In order to generate quantitative data, we intend to expand this study to investigate the impact of 24-hour FM clinic opening hours on ED crowding, inpatient waiting times, number of patients leaving the ED without being seen and patient satisfaction. In addition, we also intend to investigate the frequency and nature of presentations to the FM clinic during extended hours.

This study is the first to investigate the effects of extended clinic opening hours on the diagnosis of limb complaints. Data on the influx of patients and diagnosis of fractures were compared with data from 2013 for the same 3-month period, since, during the 2013 period, the FM clinic was operational during regular hours only. However, there are limitations here, as the data from the two 3-month periods are not directly comparable: during 2013, radiography was available only until 14:00 hours. By extending opening times, the FM clinic’s capacity was increased, enabling the clinic to manage a greater number of patients in 2015 than in 2013 (602 patients during regular hours in 2015, compared with 78 in 2013).

Conclusion

We recommend that future studies seek to establish the correlation between extended FM clinic opening times and ED crowding by recording ED influx and outflow before and after the introduction of extended opening hours. In this study we report that extended FM clinic opening hours facilitates the effective management of patients with limb complaints and may reduce ED crowding.

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