ED data dispels myth about lower urgency care patients

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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