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GENERAL practice clinics co-located with hospital emergency departments and other strategies aimed at making patients avoid hospitals are a waste of time and money, says a leading Australian emergency physician.
Dr Michael Golding, director of emergency services at the Prince of Wales Hospital in Sydney, told MJA InSight co-located clinics were “a con”.
“If you have an acute problem, which are you going to choose — a 24-hour GP clinic which may or may not be well-resourced, with a doctor you don’t know, or a very well resourced emergency department?
“I would be amazed if you could find one person who would choose the GP clinic”, Dr Golding said.
His comments follow publication of research in the latest MJA which set out to estimate the proportion of patients presenting to emergency departments (EDs) who might have been better suited to be seen in general practice. (1)
The research, by a team of emergency physicians from WA, NSW and Victoria, used data from the Emergency Department Information Systems for 2009–2011 at three Perth tertiary hospitals to compare four methods for calculating GP-type patients — one developed by Dr Peter Sprivulis, one by the Australasian College for Emergency Medicine (ACEM), a discharge diagnosis developed by the Tasmanian Department of Human and Health Services, and the method used by the Australian Institute of Health and Welfare (AIHW).
They found that all methods except the AIHW one showed that 10%–12% of patients attending EDs may have been suitable to be managed in general practice, accounting for less than 5% of the total ED length of stay. The AIHW method showed that about 25% of ED patients may have been suitable for general practice. (2)
The research authors found this to be an overestimation due to its use of the Australian Triage Scale, which they described as “an urgency rather than a complexity scale”. They recommended the AIHW method no longer be used to estimate the number of GP-type patients presenting to EDs.
An editorial in the same issue of the MJA challenged the distinction between “general practice patients” and ED patients, saying “there are just patients, who need medical care”. (3)
Dr Golding agreed, saying “this is about identifying a divergence in how emergency medicine regards itself”.
“Emergency physicians and GPs are at opposite ends of the same continuum, and there is an enormous overlap in the middle of patients who can be treated by both groups”, he said.
“Emergency medicine is, in effect, acute general practice.”
Associate Professor Patrick Bolton, of the department of public health and community medicine at the University of NSW, said that the issue of the “burden” of GP patients on EDs was “a furphy”.
“In Australia, you’d have to have been living under a rock not be aware that if they go to an ED there is a risk that they will have to wait to be seen”, he said. “Patients are making a decision to go to the ED for a variety of good reasons — financial, geographic, 24-hour access, resources.
“The second point is that, from an ED perspective, the less serious patients will be treated at marginal cost and will be fitted around the more urgent cases. If they have to have an x-ray, for example, then the allocated cost might be $100 but the marginal cost is next to nothing.”
Dr Golding said “hospital-avoidance” measures, such as co-located clinics and health advice phone lines, didn’t work and missed the point.
“We’ve tried all these things for stopping people from coming to emergency departments”, he said. “They don’t work. As we get better at providing service the question of waiting times will disappear.
“So, what’s wrong with coming to the ED?”
The ACEM’s latest report on hospital ED performance, access and staffing supported Dr Golding’s claims. (4)
“The majority of directors of emergency medicine disagreed or strongly disagreed with the statements that low-acuity GP-type patients contribute substantially to the workload, are a significant contributing factor to ED overcrowding or that they are a significant resource burden”, the report said.
“Interestingly, the majority of [directors of emergency medicine] also disagreed or strongly disagreed with the statement that diversion initiatives for low-acuity patients (eg, GP telephone helplines and after-hours GP clinics) have reduced patient workload."
1. MJA 2013; 198: 612-615
2. AIHW 2010; Australian hospital statistics 2009-2010: 12-14
3 MJA 2013; 198: 573-574
4. ACEM 2013; Hospital Data and Accreditation 2012 Survey — Part 1: Report of Findings
I too agree with Sue. And with the comment, “there are just patients, who need medical care”. After working in public hospitals for more than 15 years, I think this is the wisest statement I have heard in a very long time and a concept that has been largely forgotten. One of our large tertiary hospitals in Melbourne used to have the motto “Service and Care”. It’s been replaced with a page long statement of “Vision, Mission and Values drawn up by the corporates. How much better would things be if we could stop shifting costs around and get back to the business of service and care. Where I do agree with Bill though is regarding the inpatient physicians taking a greater interest in the undifferentiated medical patient. Why this need to have it all served up on a plate by someone else? Can a diagnosis not evolve? Is there not an intellectual challenge and exercise in working this stuff out? Is it not stimulating? Or are we so focused on “work avoidance” (it has always been a badge if honour for a medical registrar to be a “wall”) that we have lost the joy in learning and discovering? Sadly it is probably a reflection on people just being too busy and unsupported, such that the call from the ED regarding one more patient fills inpatient registrars with dread……..although I believe there are cultural factors at work here, too. But once again, in her wisdom, Sue is correct. This is not new. This has been going on for ever, and ever. And ever.
BIll – many different services contribute to the provision of ”acute services” – both in the community and in hospital. The Emergency Department is the only service that provides round-the-clock unsceduled acute care that can manage patients throughout the spectrum of acute care, at all levels of complexity, in a team-based environment, and with on-site investigations. The service is not only chosen by patients directly, but provides an essential back-up and second opinion for the community medical sector as well. All sectors for acute health provision have some overlap. GPs manage children with asthma, so do paediatricians. GPs manage adults with hypertension – so do cardiologists. GPs manage diabetics – so do endocrinologists. But why is there no call to define a “GP-type asthmatic” or a ”GP-type diabetic”? Because the funding source is the same – so no incentive to cost shift.
The poll….very small number (not many more responses than the other recent polls).
Was it really the right question? Is the issue about inappropriate use of EDs or about different ways in which acute presentations can be managed?
Hmmm…the poll results are interesting. I wonder how they would look if divided into “voters who know about current Australasian ED casemix” and “other”.
In my >20 years of practice (mainly Emergency Medicine) spanning 3 countries, my view matches Sue’s far more than it matches Bill’s. I think it is quite unhelpful to claim any potential superiority of FRACPs in managing such cases over FACEMs either. The fact is that such patients need a doctor with an interest (and skills) in providing acute care at the front door, 24/7. These doctors require a great breadth of clinical exposure across specialties.
When emergency medicine (and indeed, intensive care) first came into existence, it was in response to a need for senior doctors to guide the care of undifferentiated and acutely unwell patients. Previously junior staff had been left to learn by their mistakes in public hospitals and the traditional consultants of the time had relatively little interest in the acutely unwell (they had, after all, already “done their time in the pit” as juniors, graduating to private practice etc.)
We have largely fixed that problem but now another is emerging, namely increasing complexity and fragmentation of care (multiple providers). Emergency Physicians are still as well-placed as (if not better than) any craft group to provide an after-hours access point for patients in need (the patients usual doctor can’t be available 24/7). But what we need now is a better system for dealing with these complex patients, and providing continuity of care by teams that know them well. And this could lead into another huge post, but I will stop there!
On the contrary, ”bill”. I have worked as a consultant in North America, where emergency medicine developed. I have also visited South Africa, where emergency medicine hardly exists, if at all, despite a strong need. Not only have I worked as an ED consultant for 20 years, but one of my research areas is ED casemix as well as models of care, so perhaps I am more informed in this area than some others in this discussion. ED specialists do not want to ”have their cake and eat it” – we want to apply our skills in ways that they most benefit patients, without being hammered for our own successes. There is no such thing as a “GP patient” or ”ED patient” – just as there are no “physician patients” – there are just patients with needs. It appears we are under constant criticism for catering to these needs. In other areas of life, this is called ”success”. I don’t begrudge the resuscitation role – just point out that it is a tiny minority of our casemix.
Sue Ieraci’s response suggests she has never worked outside Australia.What is this “evidence” that is referred to?? Perhaps everyone should take a deep breath and drop all assumed roles OTHER than treating the critically unwell and try something new (for Australia – according to Sue), so far all other redesigns have been tinkering around the edges and made little or no difference – I think you will definitely find evidence for this!.The model described worked extremely well in South Africa during a time when there were no specialist emergency physicians. And by the way – “old fashioned” refers to how things are being done here , and according to Sue for quite a long time! I think it is she who is maintaining dellusions and illusions. I am disappointed that she thinks the comment ” bringing the nearly dead back to life ” is condescending, it sounds as though she begrudges this role. I absolutely agree that the combination of “tyranny of diagnosis”, a risk averse governance system, sub-specialists unwilling to look after all but the well defined clinical problem and in-patient colleagues unwilling to cooperate are all contributing factors. However until the ED specialists 1. take a stand and 2. relinquish all those other roles referred to above I very much doubt that things are going change substantially.Currently the way I see this is that they want to both have their cake and eat it.
An excellent article – thank you. “Bill the physician” appears to maintain old fashioned delusions, however, despite the evidence. In my thirty years of medical practice, there has NEVER been a time when inpatient medical teams embraced undifferentiated acute care – it was always “call me when all the tests are back”. It happened when I was an intern, it happens even more today -because there are more available tests. And as for the condescending ”very good at bringing the nearly dead back to life” – that represents a tiny proportion of emergency medicine, which provides acute care, complex work-ups, second opinions and rule-outs. The real curse of acute medicine is the narrow sub-specialisation that sees a cardiologist no longer able to treat a chest infection that precipitated heart failure, or a surgeon that can’t make a decision without a CT. In this I do agree with bill: ”CTPA and troponin in my view being the most poorly used tests) this ingrained approach of establishing a conclusive diagnosis has contributed to the clogging of EDs.” But why generates this demand? The ”tyranny of diagnosis” is not driven by Emergency Physicians, but by a combination of a refusal by inpatient sub-specialists to accept care, and a risk-averse clinical government system that sees a delay in definitive diagnosis as a ”miss.” Multiple policies exist to allow ED doctors to make admission decisions without a definitive diagnosis. Why won’t inpatient colleagues cooperate?
……continued….If we (physicians) had the foresight years ago to recognise that morbidity expansion was going to be the greatest challenge to bed occupancy we might have been able to influence better the entire process of managing the acute presentation such that most patients did not go via EDs and into the care of emergency physicians.
The RACP should reclaim the space of initial assessment of MOST patients that present to the ED that have been triaged such that they are most likely going to need in-patient medical management but not emergency resus / stabilisation. This means that a very skilled triage process has to occur and needs to be more thoughtful than the current process of prioritisation.
This is not to say that I think emergency physicians are not a necessary and valuable craft group – they are essential for and very good at bringing the nearly dead back to life and establishing the next hours of stabilisation of the critically ill, but I think that is where their role should end.
If this were to be the case then we would not need to build increasingly larger EDs and staffing them accordingly, we could use those funds for properly resourced ‘medical admission wards’. Of course we would need to go back to training medical registrars (and probably the most recent generation of Fellows) in the skills of managing the acutely unwell with undifferentiated problems without the luxury of knowing what the serial serum rhubarb levels are. here’s hoping.
Are EDs and ED physicians doing work that they should not be? If yes then the questions are why and if not them then who?
So from a hospital physician point of view, I think that patients are languishing in EDs because we physicians have become so wedded to the Single Organ Doctor concept that we can no longer cope (clinically and emotionally) with the undifferentiated patient who has not had multiple (mostly unnecessary investigations), hence ED docs (FACEMs and trainees) have been coopted into “sorting out” the problem. During the times of less clinical and political pressure, this would have appealed to them as an intellectual and clinical challenge. However with the rapid expansion of comorbidity and easy accesibilty to an increased number of tests (CTPA and troponin in my view being the most poorly used tests) this ingrained approach of establishing a conclusive diagnosis has contributed to the clogging of EDs. It seems to me that what ED docs are yet to learn sufficiently is when to realise that it is seldom optimal care to assume that for every presentation the least likely (but possibly most serious condition) HAS to be conclusively excluded and that the only way to do this is to insist on either an ‘immediate’ specialist review or an in-patient stay and there are now expanding modalities of community-based care. In response governments – who always grab the low-hanging fruit – have responded by building even larger emergency departments and funding more staff positions and so have really just encouraged an inefficient and suboptimal approach to clinical reasoning and management….to be continued…
The title of this article states that low-acuity patients are “not an ED problem”.
The justification of this statement is that this patient population comprises “only” 10-12% of the ED case load.
It is stated here that these patients impose a “next-to-nothing” marginal cost on society because the patients are seen in between true emergencies.
However, is the cost truly “next to nothing”?
This argument (that “in-between” patients add little marginal cost) implies that there is “in-between” time exists in the first place.
Just imagine if every ED had 10-12% fewer nurses and ED physicians. (But, of course, there is an equivalent increase in the GP population). In this alternative scenario, the low acuity patients would be seen in a less labour-intensive setting (which is safe and appropriate to their acuity level).
Just a thought.
An excellent paper. You have hit the nail on the head. The only problem is that you cannot expect federal or state governments to have any insight or commonsense in respect of health provision.
The prime issue behind this paper of course is to refute the assertion that if only General Practitioners were more available, the pressure on EDs would be less. I note that a study published in Emergency Medicine Australia in 2007 (Emergency Medicine Australasia (2007) 19, 333–340) demonstrated that the three major reasons given by patients attending the ED rather than their GP were:
1. My health problem required immediate attention and was too urgent to wait to see a GP or medical centre (67%)2. My health problem was too serious or complex to see a GP or medical centre, including after-hours (38%)3. I am able to see the doctor and have any tests or X-rays all done in the same place at the ED (51%) All of these relate to perceptions rather than the actual diagnosis or resource use of the patients. The State Governments are eager to promote the excellence of care at their major hospitals and how quickly you will be seen. General Practices are not promoting anything similar. In today’s world where instant satisfaction is highly valued (fast food, ATMs, mobile phones) the results are clearly apparent. Lastly, it seems unusual that a study purporting to identify GP-type patients amongst a cohort of ED presentations doesn’t have a single GP as a co-author.
“once.upon.a.time” ED was called A&E(accident & emergencies) Departments……………………
It is good to see a real evidence base for the issues we currently face in healthcare, and not just case study extrapolations which unfortunately seem to be the norm.
The issue is an ageing population with increased frail elderly who land in the ED when they get too sick to manage at home or in residential facilities. The GP can do their best to keep them stable, but unfortunately they are working with a very frail substrate, so the fine line between managing in the community and needing acute care is being stretched.
Whilst ED may not be the optimal place for their management, it is beyond the scope of the average suburban GP clinic. They need acute care and the right resources. They also need an active plan for managing them during and after the acute care intervention.
It is time to rethink our options, develop new models of care suitable for such patients, and make sure they are proerly resourced and reimbursed. Tinkering around teh edges won’t solve the problem, it needs transformative thinking.