The National Department of Health’s Referral Policy for South African Health Services and Referral Implementation Guidelines recommend that patients access health services at the primary level of care closest to their homes (National DoH 2020). Primary healthcare (PHC) clinics aim to effectively deliver healthcare, ensuring accessibility, affordability, efficiency, and fair distribution of services to their respective communities. Many patients, however, choose to receive care at an emergency department (ED) for minor ailments that could be managed at the primary care level. This practice is viewed as an ‘inappropriate use’ of hospital-based EDs (Alnasser et al. 2023; Al-Otmy 2020; Keizer Beache & Guell 2016). Research shows that this practice contributes to overcrowding and overuse of resources in EDs (Alnasser et al. 2023; Gulacti & Lok 2018; Matifary et al. 2021), negatively affecting the quality of service delivery and causing patient dissatisfaction (Keizer Beache & Guell 2016). The use of emergency services for non-urgent conditions is a global concern, and many healthcare workers find such visits inappropriate regardless of the context in which they occur (Matifary et al. 2021).

The reasons behind the trend in ED attendance for non-urgent conditions are multifaceted and complex. Access, financial reasons, perceived severity of the health conditions, convenience and proximity to the ED, the expectation of special investigations, and the lack of confidence in primary care practitioners were cited as reasons for attending EDs rather than PHC clinics (Fatima et al. 2021; Minderhout et al. 2019). Patients’ expectations of better healthcare were cited as reasons for visiting EDs rather than clinics (Matifary et al. 2021). Because many patients have trauma-related complaints, some feel they can only be treated at hospitals offering X-rays (Al-Otmy et al. 2020; Fatima et al. 2021; Henninger, Spencer & Pasche 2019; Koce, Randhawa & Ochieng 2019).

Minderhout et al. (2019) in the Netherlands found that self-referred patients preferred hospitals because of perceived convenience and better available facilities. The lack of information regarding where to go and poor access to their general practitioners (GPs) also played a role (Minderhout et al. 2019). Fatima et al. (2021) reported similar findings in a study investigating the factors influencing general practice-type presentations to the ED in a rural Australian community. A qualitative study from Switzerland found that the quality of their relationship with the GP influences patients’ decisions on whether to consult the GP or visit an ED (Henninger et al. 2019).

Al-Otmy et al. (2020) reported that 78.5% of patients visiting the ED of a tertiary hospital in western Saudi Arabia did so for non-urgent conditions. The primary reasons for self-referral were the patients’ perception that their condition was urgent and the easy accessibility of the ED. Similarly, a Nigerian study found that 60% – 90% of patients self-refer to higher levels of care due to limited understanding of the healthcare system, perceptions of symptom severity, beliefs about better equipment and facilities in the ED, and advice from family or friends (Koce et al. 2019).

Self-referrals to inappropriate levels of care were associated with a lack of access to PHC in South Africa and the ease with which non-urgent patients could access hospitals. Other factors contributing to their health-seeking behaviour were their perception of their illness as serious, the lack of medical insurance, and the time of day they sought treatment (Keizer Beache & Guell 2016; Pillay & Mahomed 2019; Rajman & Mahomed 2019).

A systematic review by Uscher-Pines et al. (2013) estimated that around 30% of ED visits in the United States are for non-urgent conditions. Factors such as younger age, the greater convenience of the ED compared to other care options, and negative perceptions of non-ED care significantly contribute to these high rates. The authors suggest that the large volume of non-urgent ED visits reflects limited access to primary care and warn against the common assumption that simply redirecting non-urgent patients to other settings is an effective policy solution. They also highlight that efforts to discourage non-urgent ED use may lead to unintended consequences.

Behrens and Morgan (2023) developed an evidence-based framework to explain why people choose to visit the ED instead of a PHC facility. They identified demographic factors, such as age and deprivation, as important contributors. Additionally, the framework highlights the role of community resource organisations and patients’ perceptions, which often reflect underlying unmet needs. The authors emphasise that planning interventions should be approached with empathy and compassion towards patients.

Yeh et al. (2022), in a study conducted in Northern Taiwan, reported that while ED visits generally declined during the coronavirus disease 2019 (COVID-19) epidemic, patient numbers rebounded once the pandemic subsided.

In many parts of the world, triage scores classify patients according to their need for urgent medical care (Pillay & Mahomed 2019). A triage scale was developed in Cape Town in 2004, known as the South African Triage Scale (SATS). Many South African healthcare facilities have adopted this method, including the Robert Mangaliso Sobukwe Hospital (RMSH), a tertiary hospital in Kimberley, in the Northern Cape Province of South Africa (Pillay & Mahomed 2019; Uscher-Pines et al. 2013).

As a part of the SATS, the Triage Early Warning Scores (TEWS) assign a triage colour code based on the score; TEWS assign a 0–2 score as green (non-urgent), 3–4 score as yellow (urgent), 5–6 score as orange (very urgent) and ≥ 7 scores as red (emergency). The SATS assigns a blue code to deceased patients (Pillay & Mahomed 2019). Triage nurses at RMSH assign these triage colours primarily based on the measured vital signs and any additional clinical condition (discriminator) that warrants urgent attention (for example, chest pain) (Pillay & Mahomed 2019). A patient’s triage colour code determines their priority level (Pillay & Mahomed 2019). For this research, the SATS was used as a coding system to identify the ‘green’ non-urgent patients. The system only recognises medical or clinical factors when classifying patients as non-urgent. Patients often present to the ED without referral letters due to underlying social, economic or psychological causes (Behrens et al. 2023), but the assessment of these factors is not included in the triage forms.

Overcrowding and long waiting times in the ED at RMSH, Kimberley, have raised concerns. Patient dissatisfaction stemming from extended waiting periods has been documented through formal complaint channels (personal communication with the quality assurance department). The overcrowding issue, partly driven by self-referred patients seeking care for non-urgent conditions, leads to the excessive utilisation of resources originally designated for urgent and emergency cases within the ED.

This study aimed to describe adult patients’ characteristics and reasons for self-referral to RMSH Emergency Department, Kimberley, who were green-triaged (non-urgent) based on SATS criteria from May to July 2021.

Descriptive statistics, namely means and standard deviations or medians and percentiles, were calculated for continuous data. Frequencies and percentages were calculated for categorical data. The analysis was done by the Department of Biostatistics at the University of the Free State, Bloemfontein. The data analyses were performed using SAS software, version 9.4, from the SAS Institute Inc., Cary, NC, United States.

A total of 331 participants were recruited for the study; the mean age ± s.d. was 40 ± 16.36 years (ranging from 18 to 89 years). Table 1 shows the other demographic characteristics of the participants. Over half of the participants were unemployed (n = 181, 54.7%). Only 25 (7.6%) participants had medical insurance.

Most participants (n = 291, 87.9%) reported having access to PHC clinics. Of the 40 (12.1%) that reported a lack of access to the PHC clinics, it was due to reasons such as ‘distance from the clinic’ (25%), ‘no clinic’ (52.5%), ‘insufficient medication in the clinic’ (7.5%), ‘no doctor in the clinic’ (2.5%), ‘delay in getting help’ (5%) and ‘I live closer to the hospital’ (5%).

Most participants (n = 298, 90.1%) had no access to a private doctor. Among the participants who attended a local clinic in the past for various medical needs (n = 224), about three-quarters (n = 169, 75.5%) indicated that they were more familiar with the services rendered in the RMSH ED than in their PHC clinics, thus preferring to attend RMSH ED to obtain X-rays, CT scans, and other laboratory tests, etc.

Two hundred and thirty-five participants (71.0%) presented to the Gateway ED because they believed their medical problems required special investigations that could only be done at the hospital. Most participants (n = 310, 93.7%) believed that the severity of their medical conditions warranted attending the Gateway ED rather than their PHC clinics. This information is depicted in Table 2. Other reasons were grouped according to the frequency of related responses, as shown in Table 3.

This study examined the characteristics and reasons why green-triaged patients present to the RMSH Family Medicine Gateway Centre. Patients’ self-referral greatly affects waiting time and incurs more costs for the healthcare systems (Rajman & Mahomed 2019). Many green-triaged self-referred participants were males, single, unemployed and not on a social grant. Similar findings were reported by Rajman and Mahomed (2019) in a study of self-referred patients at a hospital in KwaZulu-Natal, where the majority of participants were male, single and unemployed. They also reported that most of their patients were less than 39 years of age, which is in keeping with the current study, where a significant majority were between 18 and 45 years (Rajman & Mahomed 2019). The reason for this trend may be due to the younger, male, unemployed patients seeking employment in the areas near the hospital and preferring to access the hospital that is nearer to them rather than having to travel back home to their clinics.

The majority of participants in this study reported having no chronic medical conditions, which is similar to the findings by Krause et al. in patients with spinal injuries with self-reported ED visits (Krause, Cao & DiPiro 2022). Another study by Idil et al. (2018) in Turkey had similar findings, with 80.3% of self-referred patients presenting with no chronic disease. In the current study, this is understandable, considering the younger age bracket of the majority of the participants.

Most participants had no medical insurance and access to a GP, probably because they were unemployed and could not afford the cost of a general practice consultation. This is supported by the findings of Maseko and Harris (2018), who explored public perceptions of private and public hospitals in their study. It explored the financial aspects of private and public hospitals, including affordability, public trust and the acceptability of healthcare services. Kraaijvanger et al. (2016), in a meta-analysis of the motives for self-referral to the ED, described affordability as one of the main reasons for self-referral.

Insufficient resources at different healthcare facilities to offer diagnostic services like blood tests or radiological examinations to patients who require them, along with the need to establish an adequate number of clinics in every community, maintaining proper medication supplies, and ensuring regular doctor visits to clinics for patient support may lead individuals to circumvent existing referral procedures and seek assistance in facilities where they can obtain these services. This can result in an excessive burden on these facilities. This study found that some of the reasons given for bypassing the PHC clinics and local GPs to self-refer to the ED were similar to findings from other studies such as ‘needs for special investigations’, ‘radiologic or blood investigations to get a diagnosis’, ‘perceptions of having serious medical conditions’, ‘no clinic’, ‘insufficient medication in the clinic’, ‘no doctor in the clinic’ and ‘delay in getting help at the clinic’ (Abere, Atnafu & Mulu 2021; Henninger et al. 2019; Kraaijvanger et al., 2015, 2016; Pillay & Mahomed 2019).

Most of the self-referred participants in this study presented commonly with musculoskeletal pain, COVID-19-related symptoms and physical injuries. While numerous studies conducted during the COVID-19 pandemic reported a decline in overall ED attendance (Fyntanidou et al. 2022; Lateef 2020), Daniels et al. (2021) observed a contrasting trend, and he reported an increase in ED visits among frequent attenders presenting with medically unexplained symptoms (Daniels et al. 2021). Musculoskeletal pain and injuries were reported by Kraaijvanger et al. (2015) as being the common reasons for ED visits by self-referred patients in a Dutch hospital. Participants in the current study may have self-referred because they perceived that their medical condition was severe enough to warrant radiological imaging or more potent analgesics than what is available in other healthcare facilities.

This study looked at the characteristics and reasons of self-referred, green-triaged patients presenting to the RMSH ED in Kimberley. These patients were mostly male, single, less than 45 years and unemployed who believed they had serious conditions requiring urgent medical care and specialised investigations. It is necessary for the provincial health department to educate patients about the services available at the PHC clinics and the appropriate use of EDs.