Primary care professionals providing non-urgent care in hospital emergency departments

Abstract

Background In many countries emergency departments (EDs) are facing an increase in demand for services, long-waits and severe crowding. One response to mitigate overcrowding has been to provide primary care services alongside or within hospital EDs for patients with non-urgent problems. It is not known, however, how this impacts the quality of patient care, the utilisation of hospital resources, or if it is cost-effective. Objectives To assess the effects of locating primary care professionals in the hospital ED to provide care for patients with non-urgent health problems, compared with care provided by regular Emergency Physicians (EPs), Search methods We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialized register; Cochrane Central Register of Controlled Trials (The Cochrane library, 2011, Issue 4), MEDLINE (1950 to March 21 2012); EMBASE (1980 to April 28 2011); CINAHL (1980 to April 28 2011); PsychINFO (1967 to April 28 2011); Sociological Abstracts (1952 to April 28 2011); ASSIA (1987 to April 28 2011); SSSCI (1945 to April 28 2011); HMIC (1979 to April 28 2011), sources of unpublished literature, reference lists of included papers and relevant systematic reviews. We contacted experts in the field for any published or unpublished studies, and hand searched ED conference abstracts from the last three years. Selection criteria Randomised controlled trials, non-randomised studies, controlled before and after studies and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs to attend to non-urgent patients, as compared to the care provided by regular EPs. Data collection and analysis Two reviewers independently extracted data and assessed the risk of bias for each included study. We contacted authors of included studies to obtain additional data. Dichotomous outcomes are presented as risk ratios (RR) with 95% confidence intervals (CIs) and continuous outcomes are presented as mean differences (MD) with 95% CIs. Pooling was not possible due to heterogeneity. Main results Three non randomised controlled studies involving a total of 11 203 patients, 16 General Practioners (GPs), and 52 EPs, were included. These studies evaluated the effects of introducing GPs to provide care to patients with non-urgent problems in the ED, as compared to EPs for outcomes such as resource use. The quality of evidence for all outcomes in this review was low, primarily due to the non-randomised design of included studies. The outcomes investigated were similar across studies; however there was high heterogeneity (I2>86%). Differences across studies included the triage system used, the level of expertise and experience of the medical practitioners and type of hospital (urban teaching, suburban community hospital). Two of the included studies report that GPs used significantly fewer healthcare resources than EPs, with fewer blood tests (RR 0.22; 95%CI: 0.14 to 0.33; N=4641; RR 0.35; 95%CI 0.29 to 0.42; N=4684), x-rays (R...

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

“…Nine papers were included in the review: 10,143,[197][198][199][200][201][202][203] two systematic reviews, 10,197 which included 28 individual papers, and seven additional papers. 143,[198][199][200][201][202][203] The results of the review sifting process are given in Figure 5.…”

“…Two systematic reviews 10,197 examining the evidence on the clinical effectiveness and cost-effectiveness of primary care services associated with EDs included findings from 28 studies. Both concluded that, although there was some evidence that locating primary care services within or close to EDs could reduce ED attendances may save resources by using fewer diagnostics and referrals for admission and potentially could reduce costs, the evidence base to support development of this model of care was weak and based on poor-quality studies.…”

“…The authors of the two systematic reviews identified a range of limitations to the studies included in their reviews, including small sample sizes in the form of low response rates, lack of data on patient waiting times, length of hospital stay, adverse effects or mortality and a lack of consideration of patient safety issues. 197 The review by Fisher et al 10 also identified the poor research design and reporting of studies, including variability in study design and length, sample size, period of follow-up and definitions of primary care/non-urgent type condition. Individual authors of included studies have acknowledged the difficulties of conducting randomised trials in this difficult environment.…”

Unplanned reattendances at the paediatric emergency department within 72 hours: a one-year experience in KKH

“…(39)(40)(41)(42) Studies have shown that introducing 24-hour primary care services led to a reduction in paediatric ED visits, particularly in nonurgent cases. (43) Maintaining continuity of care with primary physicians may also reduce rates of admission for children with comorbidities.…”

A comparative study of patient characteristics, opinions, and outcomes, for patients who leave the emergency department before medical assessment

“…1 This model often results in long waiting times, overcrowding, patient dissatisfaction, high walk-out or left-without-being-seen (LWBS) rates for those categorized as lower priority. 1 Although LWBS rates are routinely tracked, monitored, and used as an indicator of ED performance, there is limited knowledge about why people leave or whether they seek alternate care.…”