ijphcs - International Journal of Public Health and Clinical ...

International Journal of Public Health and Clinical Sciences e-ISSN : 2289-7577. Vol. 3:No. 5

September/October 2016

Arinah W. D. S., Faisal I., Muhamad Hanafiah Juni, Ismail, I., Mohamed, A. S 159

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Open Access: e-Journal

FACTORS ASSOCIATED WITH EMERGENCY

DEPARTMENT GREEN ZONE UTILIZATION IN HOSPITAL

Arinah W. D. S.1, Faisal I.

1, Muhamad Hanafiah Juni

1*,

Ismail, I.2, Mohamed, A. S.

3

1 Department of Community Health, Faculty of Medicine and Health Sciences, Universiti

Putra Malaysia. 2 Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra

Malaysia. 3Department of Emergency, Serdang Hospital, Ministry of Health Malaysia.

*Corresponding author: AP Muhamad Hanafiah Juni, Department of Community Health,

Faculty of Medicine and Health Sciences, Universiti Putra Malaysia 40300 UPM Serdang,

Selangor Darul Ehsan, MALAYSIA; Email: [email protected]

ABSTRACT

Introduction: In hospital, emergency departments are highly utilized by patients.

Overcrowding, congestion and long waiting time were among the issues highlighted resulting

from it. In Selangor, there has been a steady increase in utilization of emergency department

of government hospitals over the past five (5) years. Utilization of green zone was the highest

in these hospitals. Being a department that provides a comprehensive emergency service and

provides easy access for the community, issues of appropriateness utilization arise. This study

aims to determine the level of appropriateness of green zone utilization by patients attending

Emergency Department in Serdang Hospital and factors influencing its utilization.

Methodology: A cross-sectional study was conducted in Emergency Department of Serdang

Hospital. Sample size of green zone adult patients were obtained by systematic random

sampling. Emergency Medicine and Trauma Services Policy Malaysia 2012 were used to

classify patients to appropriate and inappropriate utilization of green zone. Pre-tested self-

administered questionnaire were used to interview patients. Descriptive statistics, chi-square

test and logistic regression used to analyse the data collected. Data analysis conducted using

IBM SPSS Statistics version 22 and p value significant at <0.05.

Result: There were 793 (90.7%) patients in this study. It was found that level of

appropriateness utilization in green zone emergency department was 83.6% appropriate and

16.4% was inappropriate. Median age of patients were 29 years old (IQR ± 25th, 75th; 23,

40). Majority were Malays (74%). The results of chi-square test indicated that there were

significant association between marital status (p=0.032), patients attending emergency

department because treatment cost is cheap (p=0.025), emergency department operates 24

hours (p=0.045) and time of patient presentation to emergency department (p=0.001). From

the study, the multivariate results revealed that the odds of married patients (AOR=1.481,

95% CI: 1.008, 2.174) to utilize the emergency department were higher than not married

patients, the odds of patients utilize emergency department not because of the cheap treatment

(AOR=1.614, 95% CI: 1.073, 2.469) was almost two times more and lastly the odds of




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utilization after office hours were two times more than during office hours (AOR=2.117, 95%

CI: 1.388, 3.227).

Conclusion: The study revealed majority of patients utilized green zone appropriately.

Married patient, patient attend emergency department not because treatment cost is cheap and

patient attending after office hour were significantly associated with appropriateness

utilization of emergency department. Further study needed to determine the cause and effect

relationship.

Keywords: Emergency department, utilization, appropriateness, green zone.

1.0 Introduction

Emergency medicine and trauma services provide resuscitation and stabilization, diagnosis

and management of life-threatening conditions, early definitive care management and patient

disposition in emergency department. The scope of services and quality of care have

continued to grow along with the advancement of technology. It is one of the most important

ambulatory care in hospital as it is the gatekeeper of all illnesses.

In order to provide total quality management, triage service was established (Emergency

Medicine and Trauma Services Policy Malaysia, 2012). In Malaysia, government hospitals

must provide pre-hospital services and hospital-based services for the community. This

includes triage service (Emergency Medicine and Trauma Services Policy Malaysia, 2012).

The triage service counter shall be the first point of contact for all patients accessing the

Emergency and Trauma Department care. Patients are triage into red zone, yellow zone and

green zone according to priority of treatment. Red zone also known as critical zone, yellow

zone as semi-critical zone and green zone as non-critical zone.

Over the past five years there have been a steady upward trend in the total emergency

department of government hospitals utilization in Selangor State (Ministry of Health

Malaysia, 2010 – 2013). Out of the total emergency department utilization in Selangor State,

utilization of the green zone was the highest which constituted of 843,366 patients (77.2%) in

2013 (Ministry of Health Malaysia, 2013). In Serdang Hospital, the utilization of green zone

in the emergency department showed an average of 70 – 75% of the total utilization of

emergency department over the past 5 years (Ministry of Health Malaysia, 2016).

High emergency department utilization is a worrying fact and could explain the current

condition in emergency department such as overcrowding (Cunningham, 2011), longer patient

waiting time (Erenler et al, 2015) and reduced quality of care (Moskop, 2010). There have

been several studies in the literature reporting regarding appropriateness utilization of

emergency department all over the world. Unfortunately, it has not been given great attention

by the researchers in Malaysia and this motivated the present study. This study aimed to

determine the appropriateness utilization of green zone among adult patients attending

Emergency Department in Serdang Hospital and factors influencing the utilization.




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2.0 Methodology

2.1. Study design and patients

This was a cross-sectional study carried out among green zone adult patients in Emergency

Department of Serdang Hospital. The inclusion criteria were Malaysian, all patients registered

as green zone patients and adult patients (age 18 – 60). The exclusion criteria were foreigners

and patients refused to participate.

2.2. Green Zone

In Serdang Hospital, the Emergency Medicine and Trauma Services (EMTS) Policy Malaysia

2012 [MOH/P/PAK/228.12(BP)] was adopted into more specific guidelines in green zone.

Table 1: List of Usual Presentation Triage in Green Zone

Green 1 Green 2 Green 3 Green 4

Children less than 5

years

Senior citizens more

than 65 years

Chest pain – No risk

factors and not

associated with other

symptoms, normal

ECG

Abdominal pain

Abuse/Neglect/Assault

Elevated blood sugar

without any major

symptoms

Mild asthma

Acute urinary retention

Closed fracture of

upper limbs or ankle

with major angulations

Dislocations of small

joints

Diarrhea and/or

vomiting with

dehydration

Non-aggressive

psychiatric patients

Foreign body

Minor allergic reaction

Burns <15% of BSA

regardless of depth

and/or <10% 3rd

degree burns

Minor trauma

Diarrhea and/or

vomiting with no

dehydration

Lumps and bumps

Abdominal pain:

chronic

General medical

conditions or minor

illnesses not requiring

monitoring

Ear ache

Nail prick

Acute infective eye

conditions

Fever >38º for adult

age

Fever in children

between 6 to 12 years

of age

Sore throat – no

respiratory symptoms

Simple skin diseases –

chronic

Simple upper

respiratory tract

infection in adults

Chronic trauma

injuries >6 months

Missed appointments

Medications exhausted

Second opinion

seeking

Wound dressing and

opening stitches (STO)

Medical Certificate

Specialist clinic cases

Routine change of

urinary catheter and

naso-gastric tube

Sore throat – no

respiratory symptoms

Simple skin diseases –

chronic

Simple upper

respiratory tract

infection in adults

Chronic trauma

injuries >6 months

Missed appointments

Medications exhausted

Second opinion

seeking

Wound dressing and

opening stitches (STO)

Medical Certificate

Specialist clinic cases

Routine change of

urinary catheter and

naso-gastric tube

Adopted from Emergency Medicine and Trauma Services (EMTS) Policy Malaysia 2012

It was subdivided into Green 1 for non-critical patients who require many resources; Green 2

for non-critical patients who require minimal resources; Green 3 for non-critical patient but

do not require resources attending during office hours; Green 4 for non-critical patient but do

not require resources attending after office hours and during the weekend. List of patient’s

presentations at green zone used to triage as shown in Table 1.




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2.3. Appropriateness of Utilization

In this study, appropriateness of green zone utilization in emergency department was

determined by two steps: begin with triage of green zone patients according to patient’s

presentation upon arrival and finally end status of patient after consulted and examined by

attending doctor. Patients triaged to Green 1 and Green 2 were considered as appropriate

utilization regardless of the end status of patient (admitted or discharged). Patients triaged to

Green 3 and Green 4 were seen by attending doctor for consultation and examination. Then

the attending doctor decide the end status of the patient to determine the level of

appropriateness. If patients required admission to ward, they were considered as appropriate

utilization. If patients discharge home, they were considered as inappropriate utilization. In

Green 3 and Green 4 decided by attending doctor to be admitted to ward, they were

considered as appropriate utilization.

2.4. Data Collection

Patients were randomly selected using systematic random sampling over the period of two

weeks. Data obtained from the hospital system on the attendance of green zone adult patients

in January 2016 at Emergency Department Serdang Hospital per week. Simple random

sampling for the first number and systematically with the sampling fraction of two (2) until

completing the required number of sample size. Total number of patients required were 874

patients. However, 81 questionnaires were either not collected as the patients did not show up

for consultation or incomplete form thus giving the overall response rate of 90.7% (793

patients).

2.5. The study instrument

A structured questionnaire adapted from Selasawati et al. (2007) was pre-tested and used as

self-administered questionnaire for data collection. The questionnaire consists of four (4)

sections. Section A contained 7 questions on socio-demographic. Section B was on patient’s

knowledge on the roles and functions of emergency department and were measured as “yes”,

“unsure” and “no”. For the purpose of analysis, the answers were classified into “correct

knowledge” and “wrong knowledge” and analysed individually. Section C consisted of 9

questions on patient’s perceptions of emergency department. The answers ranges from

“strongly agree”, “agree”, “neutral”, “disagree” and “strongly disagree”. Each questions were

analysed individually and the results were collapsed into “disagree”, “neutral” and “disagree”

when perform analytical study. Section D component on reasons patients attend emergency

department over other healthcare facilities. Patients chose one or more reasons. Section E

recorded the time of presentation of patients to green zone emergency department.

Questionnaire was discussed with the experts in the field for content validity. Internal

consistency method used to determine the reliability of the questionnaire with Cronbach’s

Alpha values of 0.73 for knowledge and 0.74 for perception.

2.6. Data analysis

Data analyzed using IBM SPSS Statistics version 22. Descriptive statistics used to measure

frequency, percentage, mean and median. Chi-square test used to measure association




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between two categorical of dependent variables (level of appropriateness utilization) and

independent variables (socio-demographic, knowledge of patients on roles and functions of

emergency department, patient’s perceptions of emergency department, reasons for preferring

emergency department and time of presentation). Logistic regression test conducted to

determine the predictors of green zone utilization in Emergency Department, Serdang

Hospital.

3.0 Results

3.1. Level of appropriateness utilization

This study revealed that out of 793 patients in green zone, 660 were triaged to G1 and G2

(appropriate utilization). Remaining 133 patients were triaged to G3 and G4. Out of the 133

patients, three were admitted to ward (appropriate utilization) and 130 were allowed home

(inappropriate utilization). Therefore, total appropriate utilization were 663 (83.6%) and

inappropriate utilization were 130 (16.4%)

3.2 Socio-demographic characteristics

More than half (53.5%) of the patients had their ages within the range 18 to 30 years with

median age 29 years old (IQR ± 25th, 75th; 23, 40). Male and female gender both showed

almost an equal number of patients with male at 53.5% and female 46.5%. Malays constituted

the majority ethnic group among patients 587 (74%). Patients’ level of education were mainly

till secondary school (55.4%). In employment status, working in private sectors (45.9%) were

the most. About two third of patients (60.9%) with income per month less than RM1500.00.

3.3 Factors associated with appropriateness utilization of emergency department

Table 3 below showed an association between socio-demographic characteristics and level of

appropriateness of green zone utilization in emergency department. Appropriate utilization of

emergency department was among patients aged 41-50 years old (87.7%), male (84.7%),

Chinese (86.9%), married (86.2%), patients with education until secondary school (84.5%),

patients working in government sectors (86.2%) and patients with income per month of RM

3001 – RM4500 (95.2%). Highest inappropriate utilization was patients age 18-30 years of

age (17.9%), female (17.6%), Indian (23.9%), not married (19.5%), patients with education

level of pre-university and above (17.4%), self-employment patients (20.2%) and those with

income per month of RM1501 – RM3000 (17.2%). Marital status (χ2=4.615; df 1; p<0.032)

was significantly association with the level of appropriateness of green zone utilization in

emergency department.




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Table 3: Association between socio-demographic characteristics with appropriateness of

green zone utilization in emergency department (N= 793) Socio-demographic Utilization of Green Zone χ2 df p

Appropriate Inappropriate

n (%) n (%)

Age

18 – 30 years old

31 – 40 years old

41 – 50 years old

51 – 60 years old

348

153

100

62

(82.1)

(85.0)

(87.7)

(82.7)

76

27

14

13

(17.9)

(15.0)

(12.3)

(17.3)

2.435 3

0.487

Gender

Male

Female

359

304

(84.7)

(82.4)

65

65

(15.3)

(17.6)

0.752 1 0.386

Ethnic

Malay

Chinese

Indian

Others

498

53

83

29

(84.8)

(86.9)

(76.1)

(80.6)

89

8

26

7

(15.2)

(13.1)

(23.9)

(19.4)

5.798 3 0.122

Marital Status

Married

Not Married

374

289

(86.2)

(80.5)

60

70

(13.8)

(19.5)

4.615 1 0.032*

Level of Education

Form 1-5 and below

Pre-university and above

364

299

(84.5)

(82.6)

67

63

(15.5)

(17.4)

0.496 1 0.481

Employment Status

Unemployed

Self-employment

Government sector

Private sector

Retired

196

75

81

300

11

(85.2)

(79.8)

(86.2)

(82.4)

(100)

34

19

13

64

0

(14.8)

(20.2)

(13.8)

(17.6)

(0.0)

4.419 4 0.352

Income per month

RM0 – RM1500

RM1501 – RM3000

RM3001 – RM4500

> RM4500

403

192

40

28

(83.4)

(82.8)

(95.2)

(77.8)

80

40

2

8

(16.6)

(17.2)

(6.9)

(5.9)

5.170 3

0.160

p value significant at <0.05

Table 4 showed association between knowledge on roles and functions of emergency

department and level of appropriateness of green zone utilization in emergency department.

Among the appropriate utilization 84.9% correctly answered “Emergency department supply

medication for 5 days only” (χ2=0.592; df 1; p<0.442) and 88.3% wrongly answered “Case

such as heart attack will be treated in red zone emergency department” (χ2=3.665; df 1;

p<0.056). Patients with inappropriate utilization 17.8% correctly answered “Case such as

heart attack will be treated in red zone emergency department” (χ2=3.665; df 1; p<0.056) and

18.1% wrongly answered “Emergency department is fully equipped to treat all illness”

(χ2=0.977; df 1; p<0.323).




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Table 4: Association between knowledge on roles and functions of emergency department

and appropriateness of green zone utilization in emergency department (N= 793) Knowledge on Role and Function of

Emergency department

Utilization of Green Zone χ2 df p


n (%) n (%)

Emergency cases are given priority in

emergency department

Correct

Wrong

602

61

(83.3)

(87.1)

121

9

(16.7)

(12.9)

0.701 1 0.403

Emergency department is fully equipped

to treat all illness

Correct

Wrong

428

235

(84.6)

(81.9)

78

52

(15.4)

(18.1)

0.977 1 0.323

Emergency department supply medication

for 5 days only

Correct

Wrong

248

415

(84.9)

(82.8)

44

86

(15.1)

(17.2)

0.592 1 0.442

Case such as non-serious injury due to an

accident (no broken bones) will be treated

in green zone emergency department

Correct

Wrong

388

275

(83.6)

(83.6)

76

54

(16.4)

(16.4)

0.000 1 0.990

Case such as heart attack will be treated in

red zone emergency department

Correct

Wrong

505

158

(82.2)

(88.3)

109

21

(17.8)

(11.7)

3.665 1 0.056


In Table 5 showed the association between patient’s perceptions of emergency department

and level of appropriateness of green zone utilization in emergency department. Most of the

appropriate utilization were among patients who agreed (84.7%) that “Emergency department

is the only place for treatment to my illness” (χ2=1.100; df 2; p<0.577). Patients were neutral

(87.2%) on “Emergency department needs to provide treatment regardless of the illness

seriousness” among appropriate utilization (χ2=2.076; df 2; p<0.354). “Green zone is required

in emergency department to treat non-serious cases” were disagreed (85.3%) upon appropriate

utilization patients (χ2=0.303; df 2; p<0.859). On the other hand, patients with inappropriate

utilization 17.6% agreed “Emergency department needs to provide treatment regardless of the

illness seriousness” (χ2=2.076; df 2; p<0.354), 22.4% neutral and 22.2% disagreed on

“Patients should be treated according to their illness severity in emergency department”

(χ2=2.190; df 2; p<0.335).




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Table 5: Association between patient’s perceptions of emergency department and

appropriateness of green zone utilization in emergency department (N= 793) Patient’s Perceptions of Emergency

Department



n (%) n (%)

Referral from health clinic / private clinic is

needed to receive treatment in emergency

department

Agree

Neutral

Disagree

469

128

66

(84.4)

(81.0)

(83.5)

87

30

13

(15.6)

(19.0)

(16.5)

1.002 2 0.606

All types of illness can receive treatment in

emergency department

Agree

Neutral

Disagree

399

143

121

(83.3)

(83.6)

(84.6)

80

28

22

(16.7)

(16.4)

(15.4)

0.139 2 0.933

Patients should be treated according to

their illness severity in emergency

department

Agree

Neutral

Disagree

604

45

14

(84.2)

(77.6)

(77.8)

113

13

4

(15.8)

(22.4)

(22.2)

2.190 2 0.335

Treatment quality in emergency

department is better than health clinic /

private clinic

Agree

Neutral

Disagree

Emergency department is the only place for

treatment to my illness

Agree

Neutral

Disagree

Treatment are divided into zones (red,

yellow, green) to ensure more serious illness

are given priority

Agree

Neutral

Disagree

Less serious illness receive treatment in

green zone where the waiting time is longer

Agree

Neutral

Disagree

476

161

26

310

239

114

591

62

10

409

187

67

(84.5)

(81.3)

(81.3)

(84.7)

(83.6)

(80.9)

(83.7)

(82.7)

(83.3)

(84.0)

(82.4)

(84.8)

87

37

6

56

47

27

115

13

2

78

40

12

(15.5)

(18.7)

(18.8)

(15.3)

(16.4)

(19.1)

(16.3)

(17.3)

(16.7)

(16.0)

(17.6)

(15.2)

1.253

1.100

0.055

0.384

2

2

2

2

0.534

0.577

0.973

0.825

Green zone is required in Emergency

department to treat non-serious cases

Agree

Neutral

Disagree

495

139

29

(83.2)

(84.8)

(85.3)

100

25

5

(16.8)

(15.2)

(14.7)

0.303 2 0.859

Emergency department needs to provide

treatment regardless of the illness

seriousness

Agree

Neutral

Disagree

407

143

113

(82.4)

(87.2)

(83.7)

87

21

22

(17.6)

(12.8)

(16.3)

2.076 2 0.354




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Table 6 below showed reasons for preferring emergency department and appropriateness

utilization of green zone in emergency department. Appropriate utilization were among

patients who came to Emergency department because “No health clinic / private clinic

operating at night in my village / residential area” (83.1%) (χ2=0.148; df 1; p<0.700).

However, inappropriate utilization was among patients who came because “Emergency

department is near my house (approximately 5km)” (18.8%) χ22=2.463; df 1; p<0.117). There

was significant association between “Treatment cost in emergency department is cheap” and

level of emergency department’s appropriateness utilization (χ2=5.028; df 1; p<0.025). There

was also significant association between “Emergency department operates 24 hours” and

level of emergency department’s appropriateness utilization (χ2=4.013; df 1; p=0.045).

Table 6: Association between reasons for preferring emergency department and

appropriateness of green zone utilization in emergency department (N= 793) Reason for Preferring Emergency

Department



n (%) n (%)

Emergency department is near my

house (approximately 5km)

Yes

No

272

391

(81.2)

(85.4)

63

67

(18.8)

(14.6)

2.463 1 0.117

Quality treatment at emergency

department

Yes

No

413

250

(82.6)

(85.3)

87

43

(17.4)

(14.7)

1.000 1 0.317

Treatment cost in emergency

department is cheap

Yes

No

400

263

(81.3)

(87.4)

92

38

(18.7)

(12.6)

5.028 1 0.025*

Emergency department operates 24

hours

Yes

No

544

119

(82.4)

(89.5)

116

14

(17.6)

(10.5)

4.013 1 0.045*

No health clinic / private clinic

operating at night in my village /

residential area

Yes

No

304

359

(83.1)

(84.1)

62

68

(16.9)

(15.9)

0.148 1 0.700


In Table 7 showed an association between patient’s arrival time to green zone of emergency

department and level of appropriateness of green zone utilization in emergency department.

Appropriate utilization were those who attended emergency department after office hours

(5.01pm to 8.00am) (88.9%) and inappropriate utilization among patients attending

emergency department during office hours (8.01am to 5.00pm) (19.9%) (χ2=10.639; df 1;

p=0.001). Presence of significant association between time of presentation and level of

appropriateness of green zone utilization in emergency department.




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Table 7: Association between presentation time and appropriateness of green zone utilization

in emergency department (N= 793) Factor Utilization of Green Zone χ2 df p


n (%) n (%)

Time

Office hours

After office hours

383

280

(80.1)

(88.9)

95

35

(19.9)

(11.1)

10.639 1 0.001*


3.4 Predictors of appropriateness utilization of green zone in emergency department

Binary logistic regression was used as the analysis for predicting the appropriateness

utilization of green zone in emergency department. Four variables were included in the

preliminary model. All were significantly associated with the level of utilization of green zone

in emergency department marital status, treatment cost in emergency department is cheap,

Emergency department operates 24 hours and time of presentation. The ‘Forward-LR’ method

was selected as it produced the most number of significant predictors. The three variables

were found significant as shown as in Table 8. This study showed that the odds of married

patients were more likely to utilize the green zone in emergency department compared to non-

married patients (AOR=1.481, 95% CI: 1.008, 2.174); the odds of patients who visited green

zone in emergency department were less likely to utilize because treatment cost was cheap

(AOR=1.614, 95% CI: 1.073, 2.469); the odds of patients utilized green zone in emergency

department after office hours were about two times more than during office hours

(AOR=2.117, 95% CI: 1.388, 3.227). Time of presentation was the strongest predictors of

appropriateness utilization of green zone in emergency department.

Table 8: Predictors of appropriateness utilization of green zone in emergency department Factors B SE Wald df p AOR 95% CI

Lower Upper

Marital status

Not married

Married

0.392

0.196

4.011

1

0.045

1

1.481

1.008

2.174

Treatment cost in

emergency

department is cheap

Yes

No

0.487

0.212

5.259

1

0.022

1

1.614

1.073

2.469

Time of presentation

Office hours

After office hours

0.750

0.215

12.142

1

0.001

1

2.117

1.388

3.227





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4.0 Discussions

There are many ways to classify the appropriateness of utilization of emergency

department.As the issue is very controversial, therefore, as there is no one perfect way to

determine it. A distinctive feature in this study was patients were triaged based on the criteria

adopted from EMTS Policy produced by Ministry of Health Malaysia and end status of

patient. These were used to measure the level of appropriateness utilization of Green Zone in

Emergency Department, Serdang Hospital. This study revealed that higher percentage of

appropriate utilization (83.6%) over inappropriate utilization (16.4%). However, in another

study using different criteria, it was found that 45% of patients utilized emergency department

appropriately (Selasawati et al., 2004).

More appropriate utilization (80.4%) was seen in a cross-sectional study in Italy among

patients aged 15 and older (Bianco et al., 2003). In that study, patients were interviewed then

medical personnel required to complete the form such as final diagnosis and end status of

patients after patients were seen. Another study in Turkey also yield higher proportion of

appropriate utilization (68.8%). It was conducted in two steps: analyse data from interview

and medical records followed by retrospective classification of appropriateness utilization by

emergency department resident (Oktay et al., 2003). Higher proportion of appropriate

utilization noted in those three studies could be due to the fact, appropriateness of utilization

should not be assess before a complete evaluation of patient has been performed (Oktay et al.,

2003).

Majority of married patients utilized emergency department appropriately (86.6%) and not

married patients utilized inappropriately (19.5%) (p<0.032). On the contrary, a study in Saudi

Arabia revealed otherwise. Using Canadian Emergency department Triage and Acuity Scale

(CTAS) to triage, it was reported that more married patients utilized emergency department

for non-urgent condition (61.4%, p<0.01) (Alyasin and Douglas, 2014).

Among appropriate utilization patients, three out of five questions were answered wrongly.

This indicated inadequate knowledge despite appropriate utilization. Lack of information on

other health care facilities will lead to non-urgent visit at emergency department (Sempere-

Selva et al., 2001). This could be because education on roles and functions of emergency

department were not properly and constantly highlighted to the public. Proper understanding

on the importance of could reduce the patient load in emergency department.

In this study, 84.5% of appropriate utilization patient agreed that “treatment quality in

emergency department is better than health clinic / private clinic”. However, no significant

association with emergency department utilization (p<0.534). Similar result in a study in

Saudi Arabia (Dawoud et al., 2016). This explained the high utilization of emergency

department. However, this raised the question “Will patients utilized Health Clinics if the

quality improves?”.

There was significant association between level of appropriateness of green zone utilization in

Emergency Department, Serdang Hospital and reasons for preferring emergency department.

One of the significant association was the reason “Treatment cost in emergency department is

cheap” was significant (p=0.025). Malaysians were required to pay only RM1 when utilizing




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government health facility such as emergency department and outpatient clinic. Services

provided inclusive of examination, consultation, treatment and medication. Patients utilizing

emergency department inappropriately stated the reason for choosing emergency department

over other health care facilities was because it was cheap (18.7%, p<0.025).

The other significant reason was “Emergency department operates 24 hours” (p=0.045).

Emergency department provides wide range of services and comprehensive care for patients

as well as having feasible operating hours, which is of great convenience to the community. A

department with health staff and operating 24 hours resulting in 83.2% (p=0.045) of patients

utilized emergency department inappropriately (Khan et al., 2011). A cross-sectional study

among 28 hospitals revealed that one of the most cited and important reason and for patients

utilizing emergency department was the hours of operation. The hours include during

evening, weekend and patients unable to leave work (Ragin et al., 2005).

It was noted 88.9% of appropriate utilization of green zone in emergency department were

after office hours (1701hrs to 800hrs) and 80.1% during office hours (0801hrs – 1700hrs)

(p=0.001). It is understandable that in Malaysia, government health clinics operate during

weekdays until 1700hrs. In some of the clinics, it operates until 2200hrs and some even on

Saturdays. Klinik 1 Malaysia (K1M) on the other hand, operates everyday until 2200hrs.

Despite the government’s effort of providing access of health care to the community, it seems

insufficient. This can be reflected in this study as high utilization was among those who

attended emergency department appropriately after office hours (p=0.001).

Current study revealed that marital status was one of the significant predictor of

appropriateness utilization of green zone in emergency department (p=0.045, AOR=1.481). In

contrast to this study, a study in Taiwan found out that odds of unmarried patients utilized

emergency department inappropriately higher compared to married patients (Tsai et al.,

2010). Both studies used triage to determine the appropriateness of emergency department

utilization.

Another significant predictor was treatment cost in emergency department is cheap in this

study. Unlike certain countries, patients are not assigned to certain healthcare provider.

Patients can opt to attend government health clinics or private GP. Despite charging only

RM1 for Malaysian utilizing government health facility, our findings revealed that the odds of

patients utilized emergency department not because of the cheap treatment was 1.6 (p=0.022).

Another study in Hong Kong revealed similar results where the odds of patients utilizing

emergency department for general practitioner cases because of the lower cost was less likely

(Lee et al., 2000).

The strongest predictor of green zone utilization in emergency department was time of

presentation. The odds of utilization after office hours (1701hrs – 0800hrs) were two times

more than during office hours (0801hrs – 1700hrs). The finding was consistent with the

closure of health clinics, extended hours health clinics and K1M. This was again seen in a

study conducted in a University Hospital where the highest peak for both appropriate and

inappropriate cases were around 2000hrs (Selasawati et al., 2004). In addition, another study

reported time of presentation from 800hrs until 1800hrs was significantly associated with

inappropriate utilization of emergency department (Tsai et al., 2010).




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5.0 Conclusion and recommendation

Taking into consideration 70 – 75% of the total utilization of Emergency Department in

Serdang Hospital over the past 5 years was green zone, this study revealed higher appropriate

utilization than inappropriate utilization. Therefore, future study is needed on the

development of a more pragmatic guideline to determine the appropriateness of green zone

utilization in emergency department.

One of the most significant factors associated with the level of appropriateness of green zone

utilization in emergency department was patient time of presentation. However, future studies

needed to determine the cause-effect relationship between these two variables.

Acknowledgement

The manuscript was prepared as part of requirement of graduation in Master of Public Health

degree in Department of Community Health, Faculty of Medicine and Health Sciences,

Universiti Putra Malaysia.

This study obtained approval from University Research Ethical Committee (JKEUPM),

Universiti Putra Malaysi (Reference number: UPM/TNCPI/RMC/JKEUPM/1.4.18.2), from

the Ministry of Health via National Medical Research Register (NMRR) (ID: NMRR-15-

2227-28389), from Selangor State Health Office, Ministry of Health (Reference number:

(50)JKNS (P) 130/4 Jld 9), from Serdang Hospital, Ministry of Health (Reference number:

UPM/FPSK/JKK/100-3) and from Dr. Selasawati binti Hj. Ghazali for using questionnaire.

The authors would like to thank the Director General of Health Malaysia for permission to

publish this manuscript, Dr. Rosidah Ibrahim and staff of Emergency Department, Serdang

Hospital for their cooperation and support during data collection, and to

Declaration

Author(s) declare that there is no conflict of interest regarding publication of this article.

Author’s contribution

Author 1 : information gathering, preparation and editing of manuscript

Author 2 : review of manuscript

Author 3 : final review of manuscript and final editing






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