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Analysis of emergency department data has dispelled the myth that many people attending emergency rooms should have been seen by GPs. Experts say the actual reasons are much more complex.
According to research published today in the Medical Journal of Australia, many people presenting at emergency departments (EDs) who had been defined by the Australian Institute of Health and Welfare (AIHW) criteria as being a GP-type patient may not actually be suitable for GP care.
The data
The researchers did a retrospective chart review for all patients who presented to the Nepean Hospital ED during 1–30 June 2021.
Of the 6483 people, 1995 people were GP-type patients (30.8%) according to the AIHW definition.
The AIHW defines lower urgency care (“GP-type” patients) as ED presentations by people triaged as Australasian Triage Scale category 4 or 5, who did not arrive in an ambulance, police, or correctional services vehicle, were not admitted to hospital or referred to another hospital, and did not die.
The researchers then identified their own criteria for patients they deemed potentially unsuitable for GP care based on a literature review and their own personal criteria.
This included, “People admitted to hospital but, because of access block, for whom care had been entirely provided in the ED until their discharge; people referred to the ED by a GP; those for whom care included radiology or pathology assessments; and people who presented with symptoms or diagnoses inappropriate for GP care.
“Patients were also potentially unsuitable for GP care if they received care in the ED difficult to deliver in general practice, including an inpatient or allied health team consultation, parenteral medication or fluid administration, wound closure or formal dressings, formal limb immobilisation, and prolonged observation (eg, for head injuries or serial troponin assessments),” the authors wrote.
Using these criteria, the researchers found that 1546 of those patients were actually unsuitable for GP care.
“We found that more than three-quarters of patients deemed suitable for GP care by the AIHW criteria were potentially unsuitable,” the authors wrote.
“The AIHW definition should not be used when formulating health policy, planning, or allocating resources.”
The reason for emergency room overcrowding
Co-author Dr James Mallows was inspired to do the research because of a lack of understanding of overcrowding in EDs. He argues non-urgent patients are not the cause of overcrowding, as many EDs have a model to care for them.
“Most EDs have set up an urgent care or subacute model of care for these patients within a defined area of the ED,” Dr Mallows told InSight+.
For example, the Nepean Hospital runs a fast-track unit that is staffed by nurse practitioners.
“They do not occupy an ED bed space but are seen in an ambulatory care setting and spend most of their ED journey in a waiting room,” he said.
“The clear and undisputed cause of (access block) is a lack of inpatient bed capacity.”
GP and emergency locum Dr Jillann Farmer agreed.
“It’s not being blocked by people from general practice, it’s being blocked by people who are waiting for inpatient beds. Because a large number of the bed stock is occupied by people waiting for aged care placement or [National Disability Insurance Scheme (NDIS)],” Dr Farmer told InSight+.
State and federal divide at the core
According to Dr Mallows, at the core of the problem is the divide between state and federal health care responsibilities.
“Every few months, there is a headline stating that ‘one-third of patients do not need to be in the ED’,” Dr Mallows said.
“These reports usually go on to make comments about how these patients are causing overcrowding in the ED and that increasing GP services will stop these patients presenting — both of which are wrong.
“Usually, these arguments are linked to the state versus federal funding model and usually leads to the incumbent state government saying that the federal government needs to fix the problem through increasing funding for GPs,” he explained.
Dr Farmer agreed that the continuous blame game impedes actual change.
“It’s convenient for the health departments and ministers to blame general practice and to blame the public because they’re not accountable for either of those. It obfuscates the truth,” Dr Farmer said.
As a GP who works in EDs, she has seen the state–federal divide firsthand.
“It results in general practice being cut off,” she said.
“Just the differences in response that I get when I ring a hospital as an [ED] doctor versus when I ring a hospital as a GP are totally different. As a GP it is not unusual for the inpatient registrars to refuse to take the call saying that ‘they’ll call back’. This doesn’t happen at all in a significant proportion of cases and almost never happens while the patient is still with me.
“Calling from ED, they almost always pick up and if unable to speak, will ask me to call back in ten or 30 minutes. It’s a very different experience,” she explained.
Dr Mallows said he isn’t advocating for GP-type patients to present to EDs, but sometimes it is inevitable.
“Good GPs keep people out of hospital … However, GPs are not set up to manage acute illnesses and injuries, and many patients presenting to the ED lament that they could not get in to see their GP at short notice.
“Low urgency, low complexity patients will present to the ED and we should focus on models of care for the ED to treat these patients efficiently rather than seeing it as a state versus federal government cost shifting exercise,” Dr Mellows continued.
Dr Farmer is matter of fact.
“We’ve got to stop a situation where health ministers can dump the blame into someone else’s sector. The health ministers are jointly accountable for the health of all Australians. And they just need to stop it,” she concluded.
Read the research published in the Medical Journal of Australia
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Once again we have hospital based doctors with no indication that they have spent significant time in general practice deciding what can and can’t be managed by GPs. When I see research of this type coming from the GP sphere I will be more inclined to believe it.
‘What GPs can manage’ is primarily limited by availability of appointments, and when this is tight it’s not surprising if GPs direct things that they could manage (minor wound care, sprains and strains etc to ED. The actual time and documentation cost in these cases being managed in ED is massive compared to general practice – triage nursing, clerical time, medical records time and space use, plus the likelihood of overinvestigation and increased risk of error due to not having access to a full medical history.
GP is still the most cost effective way of managing the bulk of these presentations. The fact that ED staff can manage them does not mean they should, or that it is appropriate to.
More nursing homes or nursing care at home.
Emergency clinics .. had in NZ for 40 years, work well.
Australia? About the same as it’s “space program”, all talk but no lift off let alone a rocket.
Just regarding GP being short changed in fee-for-service treadmill, it is important not to forget that the MBS is designed to provide a rebate not a refund to healthcare services. While it is true that the MBS has been way behind in terms of renumeration when considering CPI for the last 30+ years, it is not compulsory for GPs to accept bulk billing, and private charge has always been an option.
Whether or not the patients accepts paying out of pocket for their services is a separate matter. but there is quite a bit of irony that as more of our GP-specialist colleagues move into private billing (despite that “big deal” by the current government of raising the bulk billing incentive for card holders by just $13.80 for most GP in Australia in metro regions), they find they are practicing the medicine they always been trained to do, taking the time and effort as it always should be, seeing fewer patients than they used to do but still earning the same or slightly more.
Thus private billing doesn’t necessarily improve net income but certainly improve morale and self-worth amongst the GPs I know of. When GPs are able to charge (and receive) the fees they want to charge, perhaps they are more willing to take on the kind of work GPs used to do 2-3 generations ago (and some remote GPs still willing to offer).
At the end, the GP’s decision to accept bulk billing or not, invariably involves market forces, self-confidence/belief, peer pressure in the practice/area and altruism, but I always advise junior colleagues that it is when you get sufficient stable income (often by private billing), that you can afford to be generous and charge less (or bulk bill).
Of course this article makes assumptions about “what is GP type care”. After decades of short-changing GPs in a fee-for-service treadmill, of course “they might not be suitable fir GP type care!
To Anonymous – I contacted an urgent care centre last week (suburban Melbourne) regarding a suspected fracture. Was given an appointment within 1.5 hours, seen by nurse and doctor, radiology arranged locally despite it being after 8pm. The whole episode of care could have been managed outside of an ED, except urgent care did not have leg splints. This required ED attendance nearly 6 hour wait overnight to be told they had no-one who could fit it overnight. Returned the following morning for splint. Urgent care facility was excellent, my first attendance would recommend.
Over the last 15 years as an inpatient doctor every hospital I have worked at has renovated their ED 2,3 sometimes 4 times over the course of my time there. They are constantly adding more beds, nicer settings, political attention and increasing staffing. Not once in that time has the dementia ward received the same treatment.
Medical wards face exactly the same exit block that ED faces, they are just less sexy to spend money on. We also cannot cap our numbers- which increase every time the ED is expanded. We also have to take the patients that no one else wants to take. And we would love for our patients to be back in the community rather than stuck in hospital- for their wellbeing and to ease our workload!
HITH is a great idea but it actually doesn’t solve our problems- to go home with HITH you have to be able to walk, care for yourself and be pretty close to discharge anyway. There are finite numbers of patients who are actually HITH suitable. We’re very good at these easy discharges. It’s complex family dynamics in patients with cognitive impairment who lack a suitable discharge destination that cause the exit block- and it feels like no one is helping us with these patients.
What would help?
Improved access to allied health in and outside of hospital
Prioritisation by NDIS for inpatients
Recognition that long stays in hospital are just as much a crisis as homelessness outside of hospital
Temporary accommodation that can be accessed whilst awaiting funding/assessments
More flexible funding arrangements
Improved funding for primary health to address these issues earlier
etc
I refer to Dr Sue Ieraci’s reference about HK and Singapore’s faster throughput in their EDs. Perhaps the perceived ED turnover rate needs a bit of adjustment and further information
As a family member of loved ones with health problem, this “faster throughput of ED” meant nothing whatsoever in terms of better care and is frustrating to deal with coming from Australian perspective. Suspected fractures which will significantly change care management literally take days to get done and report at the inpatient ward and even longer to get specialist consult opinion.
As a doctor I am surprised that it’s ok for patients to lie around in bed for these number of days before letting them mobilise after being “cleared” by the orthopod, whose consult was delayed due to x-ray taking days to be done and reported.
As a healthcare commentator, I wish to point out the HK and Singapore’s user-pays system, which can be a disincentive for patient to attend hospitals, but not a great disincentive for revenue generation for healthcare, hence the need to discharge patients quickly is probably felt more mostly when the 1000+ bed hosptial experienced overcrowding.
And to be clear here, several of my medical colleagues in Australia had similar experience when their loved ones are admitted for are. All of us tries to be respectful with our colleagues’ practice in public hospitals but we were all surprised at the care they received when we do not interfer or question them.
I have heard from Nurses who work at our local public hospital that in its 500 bed capacity there are at any one time 100 people not needing acute care but are waiting for accommodation. Most of those are waiting for the nursing home of their choice, while other nursing homes have empty beds. They do not want to go to these nursing homes because someone already in a nursing home is a lower priority for transfer to another nursing home than someone in a hospital bed. The newest nicest nursing home here has a waiting list of 100. Clearly not many of those might live long enough to get in. I actually rang th director of nursing at that home and suggested that is an enormous and unrealistic waiting list and if they picked a number and capped the waiting list at that, it might facilitate hospitals being able to discharge patients to other nursing homes. That request was refused!
The remaining inpatients waiting for accommodation are those waiting for group homes or other supported accommodation, find the homeless. Ther are long waits for supported accommodation. Hospitals are not allowed to just treat the homeless and then discharge when ready thy have to find somewhere for them. I don’t know who decided on this rule or why, but hospitals clearly cannot solve the homeless crisis. it seems acute care hospitals have become the accommodation of last resort, and neither state federal or local government appears to want to do anything about it, and the hospitals themselves don’t seem to want to get creative in getting these people out of hospital. In our 16 bed rural hospital we rapidly move nursing home type patients on to a suitable nursing home- once acute car is finished, we downgrade them to nursing home type, they get charged a daily fee and soon move on. For the homeless, I suggest simply pay for a week in a motel and a social worker and discharge. Cheaper than hospital days, and if the homeless persons returns to the street rather than accept the help offered that’s their affair.
As a Belgian emergency physician (EP), I fully agree that access block is the bigger problem (and not the percentage of low urgency care patients)
From a methodological point of view, however, several points need to be raised (maybe more important in Belgium than in Australia):
1. Every non-urgent patient presenting to an ED has to be evaluated. In the end, this implies consumption of time for nurses and EP’s. When the waiting room is filled with non-urgent patients and the waiting times become very long, stress increases for the staff, sometimes leading to “prioritization” of patients with a low degree of acuity above patients with a higher acuity. Consequently, non-urgent case may have an impact on the core business of an ED.
2. Referral by a GP not necessarily means that the ED presentation of that particular patient is appropriate. Sometimes, this is an indolent solution for the GP (especially occurring during a busy period). Another issue is difficult access to specialized, but non-urgent medical care; GP’s may send such a patient to the ED (because an appointment at e.g. the dermatologist within an acceptable period is not possible). As a third example, referral by the GP for hospital admission for a non-urgent condition (e.g. palliative care) may be done via the ED (and not directly to a hospital ward). In the last two situations, the GP is rarely to blame; for the ED, however, these patients inappropriately increase the work load.
3. Need for radiology does not necessarily implies the need for ED presentation. I suppose that GP’s have direct access to the radiology department in many hospitals or to a service for outpatients. Consequently, a case-by-case review is needed for these cases before one may state that these are “true” ED patients.
4. “Wound closure” is mentioned as care difficult to deliver by GP’s. Once again, a case-by-case review is necessary. I suppose there are more conditions that need such a review.
The Federal Government plan for releaving ED probllems is to fund Urgent care clinics. If the planning for this was done on the wrong information then perhaps they should re evaluate that plan. One of the problems they refeered to as being suitable was” simple fractures”, I can find the time for an extra paitient if I can get them into a Radiology Practice,am sure there is no need for reduction or Specialist folow up. There are not too many that fit that description.
The local public hospital has an Orthopedic team,Physiotherapists and an Xray departement.
I wonder how many fractures will be kept out of ED by urgent care clinics.
This long running saga is not as simple as ED’s v GPs.
1. In the mid 1980s a teaching hospital asked the University Department of General Practice in which I was a professor, to set up a teaching practice alongside their ED. It was estimated that it would save the hospital around $1m a year by accessing Medicare fees.
It was highly successful. So much so that the director of the ED
lost medical and nursing staff positions from his empire. He
stopped supporting us and
declared that suturing, foreign bodies in the eye etc were the task
of ED. Since he employed the triage nurse that is where they
went.
The GP clinic was left with the time consuming patients-those
affected by drugs, alcohol, homelessness and mental illness.
Despite the dedication and low incomes of the GP doctors the GP
clinic became financially unviable and after a 20 year struggle
closed down.
2. On the occasions that I or my wife have accompanied my now late 90+ year mother -in-law the ED has been full of drug addicts who occupy all the seats and are well known to the nurses who provide them with good humour, cups of tea and bickies. On one such occasion my m-in-law waited 12 hours to be seen and was sent back home with 4 fractures, undiagnosed.
3. A school friend and former patient has autonomic nervous system dysfunction. His labile BP varies from 230 to 40 mmHg. He shares a house with another ill friend who is often away for days at a time. When my friend falls he calls 000. In the last 4 months this has happened 5 times. He is taken to the hospital with the least ramping time. He is admitted, worked up again, and sent to a rehabilitation hospital. He is told he will be there for one month. It is usually less than 7 days. Some doctors focus on his high BP and some think it better to avoid hypotensive medications. This confuses him. He refuses aged care and cannot find a new GP in the suburb where he lives. He sings the praises of St John Ambulance and the EDs at the 5 hospitals to which he has been admitted.
4. A cousin with life-long asthma was in a bad way. She could not get an appointment with her GP of 20 years and her specialist’s receptionist said her boss would not see her without a GP referral. The GP’s receptionist advised her to go to the ED at the Teaching Hospital. I gather that this is common receptionist advice from booked up GP practices. I found a vacant appointment space in an adjacent suburb. She went and saw the GP registrar. He prescribed an inhaler that she already had and advised her to make an appointment with her regular GP.
5. We claim to have one of the best health care systems in the world. This is probably true if only the patients could access it and doctors would save time and money by communicating, civilly, with each other.
Time for several more home truths:
1. Our health care system is designed to concentrate excess workload and risk in EDs. This makes it easier for every other service, and for hospital management, but creates a poor service for patients and an awful workplace for ED staff, who are both expected to back up every other service but then watched like a hawk and crucified for delays and imperfections. There is no incentive for any other service to provide unscheduled out-of-hours services for their own patient base, or to take on excess workload or risk. Easier to send to ED.
2. Access block to the wards and ICU and mental health units causes overcrowding of ED beds. Lack of access to general practice and other community, social and mental health services causes overcrowding of waiting rooms. Both cause frustration, anger and complaints.
3. After a long career in hospital Emergency Medicine, now working in Emergency Telemedicine, I see (and live) a huge opportunity to avoid ED attendance for the many patients for whom that is not the best solution to their issue. The problem with other alternatives, when people are acutely worried about a symptom, is that they are either inaccessible or too risk-averse. Transfer of the elderly – especially if very frail and suffering severe dementia – to EDs is often poor management. Many can be assessed or managed in the RACF, in familiar circumstances and by staff who are familiar with them. The main issue driving the transfer of these patients is to transfer the risk. A better solution is to have highly experienced and competent clinicians to provide realistic risk-assessment and safe plans, agreed with patients and carers. This does not mean ordering tests as if they were in a hospital ward.
4. All five ATS Triage categories were designed for the ED setting. As others have said, they reflect urgency (=acuity) – not severity or complexity. The original scale had the least urgent category as safe to wait for hours to days. This was altered to two hours because it was thought that no patients should have to wait longer than two hours. The reality is that patients with complex issues can often wait safely for four to twelve hours or longer but may still need inpatient care. Conversely, a person with acute severe pain – like a dislocated shoulder – may need care very fast, but has a one-dimensional issue and may be discharged home from ED.
5. All major US, UK and Aus EDs suffer access block because all our systems are designed this way. Some major Asian centres such as HongKong and Singapore, have much higher ED throughput and will share the excess load with the inpatient wards. When an ED’s acute beds are all occupied by treated, stable patients who are ready to go to the ward, the least stable, yet-to-be-assessed patients are in the corridor queue. Those is a back-to-front solution which leads to avoidable harm for those waiting patients. ED’s open front door plus blocked back door makes a perfect storm. It’s known from good research that, unless the excess patients are within the view of the people managing the service, or unless it impacts on their funding, there is little incentive to change. It’s time to share the load. EDs should be responsible for unloading arriving ambulances, and managing patients for whom ED is the best solution. This can include collaborating with community services to create better pathways for people who are better served elsewhere, including virtual care. Inpatient units must be made responsible for managing the patients needing admission from ED, as soon as they are ready for that care. These are the more stable, initially assessed and treated patients. The inpatient part of the hospital needs to create solutions for them, including discharging recovering patients to medi-hotels or HITH or remote-monitored discharge.
Join the campaign to #OpenTheEDBackDoor
Great work. We all know that to be true anecdotally but hard data needed before there is any hope of being listened to by government
What is shocking is not the conclusion of multiple authors but how it was alleged AIHW used the term “GP-type” patients when considering ATS Cat 4 or 5; the AIHW did no such thing in the reference (ref 1) quoted in this Insight+ article and the paper it featured (doi: 10.5694/mja2.52034).
In fact the AIHW webpage specifically states:
“Why measure lower urgency ED presentations?
ED presentations that are lower urgency are sometimes used as a proxy measure of access to primary health care. Higher presentation rates may suggest a lack of access to GPs or other primary health services, which may have been better placed to manage a person’s health condition.
This measure is based on triage categories, which reflects urgency, not the complexity or severity of a person’s health condition, or the most appropriate and cost-efficient model of care for that region. It is important not to assume that all lower urgency ED presentations can be treated in a primary health care setting. For instance, an elderly person living in a small regional town who fractures their arm may be more appropriately treated at an ED rather than their local GP. This person may receive a triage category of 4 or 5 but may have pre-existing health conditions and need diagnostic imaging tests not readily available at the GP. Understanding how and when people use EDs can help to improve decision-making, service planning, and care coordination.”
Hence the institute had acknowledged that lower urgency care does not mean suitable for GP care.
Trying to blame AIHW for something that is really due to others is frankly misleading.
Furthermore its not just our politicians or health commentators in Australia who are guilty of promoting the ideas (not necessarily the myths) that low urgency care are predominantly suitable for GP care. UK has been doing that for years as well (ref 2).
Reference
1. https://www.aihw.gov.au/reports/primary-health-care/use-of-ed-for-lower-urgency-care-2018-19/contents/lower-urgency-care/summary
2. Royal College of Emergency Medicine, Patients Association. Time to act: urgent care and A&E: the patient perspective. 3 Jun 2015
It’s terribly frustrating. GPs know this. EPs know this.
We ALL know this. The issue in ED is access block and has been for over 20 years. Dent et al investigated this same question in 2003 and came to the same conclusion, that ED overcrowding is not a result of patients who could be diverted to GP.
https://pubmed.ncbi.nlm.nih.gov/14631698/
As clinicians we are being gaslit by governments who want us to believe we can improve processes to fix this, but until we fix access block nothing will change.
These issues have been clearly known for so long that it is amazing, not to mention extremely annoying that they are still proposed. I congratulate these authors for once again pointing out what is bleeding obvious to those of us who work in Emergency Medicine but I won’t hold my breath waiting for any meaningful change from those in power.
Good research. However we know that. But no one listens. Also the ED doctors spend more than 2-3 hours to see cases like dizziness, lightheadedness and so on . I worked in ED for years.