To GP or not to GP: a natural experiment in children triaged to see a GP in a tertiary paediatric emergency department (ED)

Abstract

ObjectiveTo evaluate the impact of integrating a general practitioner (GP) into a tertiary paediatric emergency department (ED) on admissions, waiting times and antibiotic prescriptions.DesignRetrospective cohort study.SettingAlder Hey Children’s NHS Foundation Trust, a tertiary paediatric hospital in Liverpool, UK.ParticipantsFrom October 2014, a GP was colocated within the ED, from 14:00 to 22:00 hours, 7 days a week. Children triaged green on the Manchester Triage System without any comorbidities were classed as ‘GP appropriate’. The natural experiment compared patients triaged as ‘GP appropriate’ and able to be seen by a GP between 14:00 and 22:00 hours (GP group) to patients triaged as ‘GP appropriate’ seen outside of the hours when a GP was available (ED group). Intention-to-treat (ITT) analysis was used to assess the main outcomes.Results5223 patients were designated as ‘GP appropriate’—18.2% of the total attendances to the ED over the study period. There were 2821 (54%) in the GP group and 2402 (46%) in the ED group. The median duration of stay in the ED was 94 min (IQR 63–141) for the GP group compared with 113 min (IQR 70–167) for the ED group (p<0.0005). Using the ITT analysis equivalent, we demonstrated that the GP group were less likely to: be admitted to hospital (2.2% vs 6.5%, OR 0.32, 95% CI 0.24 to 0.44), wait longer than 4 hours (2.3% vs 5.1%, OR 0.45, 95% CI 0.33 to 0.61) or leave before being seen (3.1% vs 5.7%, OR 0.53, 95% CI 0.41 to 0.70), but more likely to receive antibiotics (26.1% vs 20.5%, OR 1.37, 95% CI 1.10 to 1.56). Sensitivity analyses yielded similar results.ConclusionsIntroducing a GP to a paediatric ED service can significantly reduce waiting times and admissions, but may lead to more antibiotic prescribing. This study demonstrates a novel, potentially more efficient ED care pathway in the current context of rising demand for children’s emergency services.

The impact of general practitioners working in or alongside emergency departments: a rapid realist review

“…General practitioners in emergency departments can work in an ‘extended role’ where their skills are directed at specific patient groups including non-urgent paediatric or elderly patients (C) to treat using the usual primary care approach (M) to reduce the use of hospital resources and admissions in these patient groups (O) 5 28 43 53 66…”

“…Several paediatric primary studies supported general practitioners treating children triaged as ‘non-urgent’ to divert attendances from the emergency department,43 53 and reduce hospital admissions 5 66. None of the included primary studies described general practitioners specifically treating care home residents or the elderly, as suggested in a policy document 28…”

“…Smith et al reported an increase in antibiotic prescribing for children by general practitioners,5 which could potentially be an unintended consequence of the ‘traditional role’ approach; relying on clinical acumen and treating a suspected source of infection rather than admitting, investigating and observing the patient to confirm the diagnosis. An increase in prescribing by general practitioners was not described in other UK studies,4 25 but was reported (but not the drugs involved) in both Irish studies that involved more junior general practitioners 41 45…”

Seven days in medicine: 4-10 October 2017

“…6 Many hospitals now have GPs co-located in emergency departments, but evidence of their benefits is scant. At Alder Hey Children's Hospital, children seen by the GP service were less likely than children seen in the emergency department to be admitted to hospital (2.2% v 6.5%) and less likely to wait longer than four hours to be seen (2.3% v 5.1%), but they were more likely to be given antibiotics (26.1% v 20.5%).…”

Management of non-urgent paediatric emergency department attendances by GPs: a retrospective observational study

“…Given that an increasing number of non-urgent ED attendances are amenable to treatment in primary care, one of the key recommendations of the Royal College of Emergency Medicine is to co-locate primary care services within ED settings. [17] While the benefits of introducing GPs in EDs for managing non-urgent cases are well documented, and include increased patient satisfaction, [18][19][20][21] reduced waiting times, [19,20] and reductions in invasive examinations; [19,22] it is unclear whether this represents an efficient use of NHS resources, with the only economic analysis to date taking place in 1996 [23]. Building on our previous findings in a 6-month pilot scheme of this initiative [20] assessing clinical and process outcomes, this retrospective observational study assesses the impact of ED co-location of a primary care service on waiting times, admissions, antibiotic prescribing rates and healthcare costs; to determine the cost-effectiveness of ED co-location of GP services.…”