Can GPs Sort Out EDs?
Written by Jan Hallam
Friday, 25 August 2017
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25082017-Vickery-Alistair-Dr-May17Dr Alistair Vickery

Health Department of WA-funded research by the Division of General Practice at UWA’s Faculty of Health and Medical Sciences may offer vital data which could help address the growing overcrowding problems in the state’s emergency departments.

The trial has been completed with 15 GPs of varying levels of experience spending 2-3 sessions over several months in four emergency departments, interviewing patients who had presented to ED but were not admitted to hospital, to determine if the GP thought they could have managed the presentation in general practice.
 “Across WA, approximately 60% of people who present to ED are sent home after being managed. While there has been quite a bit of work done previously in this area, assessments to determine if presentations were primary care types were made by emergency physicians and triage urgency level. We thought it was important to study if a GP assessment could better determine the overall burden of primary care type ED presentations,” said Study leader A/Prof Alistair Vickery.

GPs, after conducting 15-minute GP-type consults with patients, had to determine one of three responses:

  • This person needed to come to ED, I couldn’t have treated them
  • I could have treated this case in general practice
  • If I had extra resources and/or training, I could have treated them in general practice.

“We didn’t ask why people were coming to ED because that is a different question loaded with a complex range of health service, sociological and cultural issues,” Alistair said.

Perhaps being free, easily recognisable, open 24 hours a day and a one-stop shop are a few compelling reasons.

The study team made some interesting observations along the way.

“ED overcrowding has been an area of interest for a very long time and all sorts of policies and processes have been tried but without evidence of effectiveness,” he said.

“For instance there was some concern around the AIHW’s classifications of triage level 4 and 5 (non-urgent) being thought of as Primary Care type ED presentations. However, clinicians recognise that urgency doesn’t necessarily reflect complexity of presentation. And equally there are some triage 2-3 presentations, while urgent, were relatively simple and could have been treated in general practice.”

“So triage levels have been found not to be a good definition of a primary care presentation.”

Researchers also had to take into account the potential bias in their patient sample.

“We had a small sample for practical logistic reasons and that subjects our sample to bias. ED physicians assessed whether patients were to be discharged and the GPs were opportunistically interviewing them, so we really didn’t know how representative our sample was of the total group of patients presenting.”

“We have recently received the linked data from the WA data collection to give us a clearer idea of what the GPs did and didn’t see which will allow us to assess that bias.”

There is considerable interest in the study because this is the first time anywhere as far as the researchers could tell, that GPs had made an  assessment of ED presentations and attempted to answer the critical question, ‘how many patients presenting to ED could have been treated in general practice’.

There are a lot of questions still to answer regardless of the outcomes of the study. If it finds that GPs could handle a significant number of ED presentations, the million-dollar question arises, how can that be achieved?

Co-located GP clinics have failed to make inroads into ED overcrowding, and the issue of continuity of care remains a critical one, particularly with the rise and rise of chronic conditions.

If it comes down to cost, as so many things do these days, is the community getting a good bang for its buck with a quick fix ED presentation?  How much would it cost to create a health system where primary and tertiary care co-operate to provide the right care in the right place?

Perhaps the answers start when there is good data on how many patients who go to ED are GP type patients.