A qualitative system model to describe the causes and drivers of frequent potentially avoidable presentations to the emergency department

Mary Malakellis; Anna Wong Shee; Margaret Murray; Laura Alston; Vincent L Versace; Steven Allender; Kevin Mc Namara

doi:10.1016/j.heliyon.2023.e21304

A qualitative system model to describe the causes and drivers of frequent potentially avoidable presentations to the emergency department

Heliyon. 2023 Nov 4;9(11):e21304. doi: 10.1016/j.heliyon.2023.e21304. eCollection 2023 Nov.

Authors

Mary Malakellis¹, Anna Wong Shee^{1

2}, Margaret Murray¹, Laura Alston^{1

3}, Vincent L Versace¹, Steven Allender⁴, Kevin Mc Namara¹

Affiliations

¹ Deakin Rural Health, School of Medicine, Deakin University, Warrnambool, Victoria, Australia.
² Grampians Health, Ballarat, Victoria, Australia.
³ Colac Area Health Research Unit, Colac, Victoria, Australia.
⁴ Global Centre for Preventative Health and Nutrition, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia.

Abstract

Frequent potentially avoidable presentations to Emergency Departments (EDs) represent a complex problem, driven by multiple interdependent and interacting factors that change over time and influence one another. We sought to describe and map the drivers of frequent potentially avoidable presentations to a regional ED, servicing regional and rural areas, and identify possible solutions from the perspectives of key stakeholders. This study used a qualitative, community-based systems dynamics approach utilising Group Model Building (GMB). Data were collected from two 3-h online workshops embedded with small-group discussions and conducted with stakeholder groups operating within a regional health system. Stakeholders were guided through a series of participatory tasks to develop a causal loop diagram (CLD) using Systems Thinking in Community Knowledge Exchange software (n=29, workshop one), identify potential action points and generate a prioritised action list to intervene in the system (n=21, workshop two). Data were collected through note taking, real-time system mapping, and recording the workshops. Each action was considered against the Public Health 12 framework describing twelve leverage points to intervene in a system. A CLD illustrating the complex and interrelated factors that drive frequent potentially avoidable ED presentations was developed and classified into four categories: (1) access to services; (2) coordination; (3) patient needs; and (4) knowledge and skills. Nine action areas were identified, with many relating to care and service coordination. Most actions aligned with lower-level system impact actions. This study provides an in-depth understanding of influencing factors and potential solutions for frequent potentially avoidable ED presentations across a regional health system. The CLD demonstrates frequent potentially avoidable ED presentations are a complex problem and identified that a prevention response should engage with system- and individual-level solutions. Further work is needed to prioritise actions to support the implementation of higher-level system impacts.