This is the first nationwide study in Sweden providing an overview of the pathways leading patients to the ED along with basic information on age, level of medical acuity, chief complaints and admission rates. In general, the current study shows that this type of data can be acquired in Swedish EDs with a high degree of completeness, although continuous reporting will require automation of the reporting process. This is an important finding, since comprehensive data even on this very basic level is currently lacking in Sweden, whereas countries such as Australia and the UK provide this information in open reports [11, 12]. Achieving a similar level of detail in the national reporting on ED attendances will be an essential step to support the development of emergency medicine in Sweden, especially in relation to benchmarking, quality assurance and the development of relevant quality indicators. National data on chief complaints, although not further explored in this report, will also provide important information to guide the development of national guidelines specific to the emerging field of emergency medicine. The main point of including such data in the current report, however, was primarily to show that it is actually feasible to collect such data on a national level.
The snapshot provided by the current study showed that the most common pathway leading to an ED visit was self-referred walk-in, which corresponded to approximately one third of all ED arrivals. A large proportion of the self-referred walk-in patients were young and had less urgent medical needs, as indicated by an overall low triage level and few patients admitted to in-hospital care (17%). Interestingly an even smaller proportion of those patients who were recommended by the national medical helpline 1177 to go to the ED were admitted (14%), suggesting that the ability of the medical helpline to assess the need for in-hospital care is likely limited. Similar patterns have been reported in previous studies which leads to the question whether some of these patients could be managed elsewhere in the healthcare system, and thereby decrease the strain on the EDs. Low acuity as indicated by triage category, as well as self-referral, have previously been reported as common factors in ED patients who could be managed in primary care [9, 19,20,21].
The causes for the high number of low acuity patients are largely unknown on a deeper, mechanistic level, but limited availability of primary healthcare may partly explain why so many low acuity patients come to the ED. [20, 22, 23] Since primary healthcare facilities in Sweden mostly operate during office hours on weekdays, and usually requires an appointment, there are many reports in the media claiming that the need for primary healthcare appointments far exceeds the capacity of the primary healthcare system. However, since there are no data on “appointments not being made”, i.e., those instances in which a patient correctly contacts the primary healthcare facility but cannot be offered a timely appointment, it is unclear to which extent the many non-urgent patients coming to the ED is an effect of a failing primary healthcare system, and how much of this phenomenon is attributable to patient-related factors. Indeed, some patients may believe that they will receive better care at the hospital ED or overestimate the urgency of their health problem [24, 25]. Another possible contributing factor is that emergency medicine is under development as a medical specialty in Sweden, and other specialities may sometimes still consider the ED as convenient venue for their semi-urgent outpatients.
In contrast, more than half of the patients who arrived by ambulance were admitted (53%). These patients were often elderly and had the highest prevalence of critical illness according to triage priority, indicating that arrival by ambulance may serve as a proxy for increased risk of severe illness. Although we did not investigate mortality in this study, our findings point in the same direction as a recent study from England, where arrival by ambulance was associated by an approximately seven-fold increase in crude mortality compared to all other modes of arrival to the ED.  Thus, the indicative effect of arrival by ambulance, as well as other pathways, on the risk for adverse outcomes should be a relevant topic for future studies.
On a systems level, the current study highlights large differences between hospitals in the contributions of the various patient pathways. This may partly be explained by geographical differences in the organization of emergency and acute care since, in some parts of the country, the ED may be the only healthcare facility available even on some weekdays, and an ambulance may be the only available means of transportation for, e.g., the elderly. However, geography alone cannot explain the large variation of low acuity patients arriving as walk-ins, or those who have been in previous contact with either primary healthcare or the 1177 medical helpline. Rather, our results indicate that the decision-making process before ED referrals or recommendations may differ, and that there is a need for clearer criteria for ED care, which is a common topic for discussion also internationally [7, 9, 26]. However, since Sweden is a geographically large, scarcely populated country with most of its 10 million population concentrated to a handful of metropolitan areas in the southern part of the country, there will always be a need for adaptive solutions to provide adequate emergency care to parts of the population living under very different geographical conditions. This means that an ED presentation which is clearly inappropriate in a large city may be the only feasible way to get healthcare in a remote, rural area. This aspect needs to be considered in future work on the appropriateness of ED care in Sweden.
The findings of the current study underscore the need for continuous reporting of information on patients’ pathways to the ED, as well as other basic information on ED patients on a national level. The fact that many of the ED attendances based on recommendations from the national medical helpline 1177 are for low acuity conditions with limited need for in-hospital care, clearly indicates that the system may partly be responsible for the increasing strain on EDs which, in turn, may negatively affect the outcomes of more severely ill patients . The UK and Australia have, in contrast to Sweden, well-developed systems for continuously reporting mode of arrival and other basic information for all ED patients [12, 27] and we strongly suggest that such a model for national reporting be implemented. Such information would provide a better understanding of ED operations and allow us to optimize resource usage and develop relevant quality indicators for emergency medicine in Sweden.