General practitioner referrals to paediatric specialist outpatient clinics: referral goals and parental influence

Non-urgent presentations to the paediatric emergency department: a literature review

It is estimated that between 58% and 82% of children and young people who present to paediatric emergency department (PEDs) have a non-urgent condition. This systematic review of the literature explores why parents of children with non-urgent conditions present to the PED rather than to community healthcare services. Five databases were searched for studies on children and young people's presentations to the PED for the treatment of a non-urgent condition, as identified by a low priority triage code. This article describes and discusses the findings of the 18 included studies.

The role of contextual factors in decision-making by General Practitioners on paediatric referral to the Emergency Department: A Discrete Choice Experiment

A General Practitioner's (GP) decision to refer a patient to the emergency department (ED) requires consideration of a multitude of factors, and significant variation in GP referral patterns to secondary care has been recorded. This study examines the contextual factors that influence GPs when referring a paediatric patient with potentially self-limiting clinical symptoms to the ED. Utilizing a discrete choice experiment, survey data was collected from GPs in Ireland (n = 142) to elicit factors influencing this decision across five attributes: time/day of visit, repeat presentation, parents' capacity to cope, parent requesting a referral, and access to a paediatric outpatient clinic/day unit. Using mixed logit models, all attributes were statistically significant, with repeat presentation and parents lacking the capacity to cope identified as the strongest contextual factors leading to the decision to refer to the ED. There has been limited exploration of this decision-making process and this study uses a robust design to identify and rank contextual attributes. Enhanced awareness of contextual factors on referral decision-making is crucial to understanding patterns of paediatric unscheduled healthcare and to planning services that respond to parent's and children's needs, whilst allowing GPs to make decisions in the best interest of the child.

Variation in referrals from primary care to scheduled paediatric services in North and East Scotland -a cross-sectional study

BACKGROUND

Factors contributing to decisions to refer children for scheduled appointments at medical paediatric outpatient clinics are not well understood. Our aim was to describe practice-level characteristics associated with referrals to general paediatric clinics.

METHODS

In this cross-sectional study the setting was general practices in three health boards in Scotland, NHS Grampian, NHS Highland and NHS Tayside The outcome was average annual number of referrals per 1000 children between 2011 and 2017. Univariate and multivariate analyses related the outcome to practice characteristics. For each practice the following characteristics were determined: distance from hospital; area deprivation; number of children registered; presence of ≥ 1 general practitioner with a child health interest and practice ownership.

RESULTS

There were 62 practices in NHS Grampian, 63 in NHS Highland, and 65 in NHS Tayside; representative annual number of referrals to paediatric clinics per capita were 22, 34, and 35/1000 respectively. In the multivariate model, the number of referrals was inversely related to number of children in the practice (0.8 % fall per 1000 children [95 % confidence interval, CI, 0.5, 1.1]) and was higher from practices in the more deprived areas by a mean 55 % [95 % CI 9, 121] compared to less deprived areas. The number of referrals from a practice rose by 0.91 % [95 % CI 0.86, 0.97] for each additional partner in the practice.

CONCLUSION

Some practice-level characteristics were related to the standardised number of referrals, and associations differed between regions.

Consultant-led triage of paediatric hospital referrals: a service evaluation

OBJECTIVE

We established a paediatric demand management (PDM) service in our paediatric department in 2017. The aim of this consultant-delivered service is to manage referrals more efficiently by providing active triage of all referrals, daily rapid access clinics and easily accessible advice for primary healthcare professionals. This study presents an evaluation of this service.

DESIGN

Mixed-methods service evaluation with analysis of data for every contact with the PDM service over a 2-year period. For each patient, the method of contact, reason for contact, presenting complaint and triage outcome were recorded. Feedback from general practitioners (GPs) and patients was gathered.

RESULTS

Data were analysed for 7162 patients. More than a quarter (2034; 28%) of all referrals were managed with advice only. Of the 4703 outpatient clinic referrals, 1285 (27%) were managed without a clinic appointment. More than half (54%) of the requests for paediatric assessment unit (PAU) admission were managed alternatively, typically with advice only or a rapid access clinic appointment. This has reversed the increasing trend of PAU admissions from primary care of preceding years. Financial analysis suggested the avoidance of these clinic appointments, and PAU admissions provided a substantial cost saving.

CONCLUSIONS

Our results indicate that the PDM service has succeeded in reducing unnecessary hospital attendances by managing patients more effectively and strengthening partnerships with primary care. The service has received overwhelmingly positive feedback from GPs. This service could be replicated in other Trusts and developed in the future to facilitate further management of paediatric cases in a primary care setting.

Factors influencing general practitioners decisions to refer Paediatric patients to the emergency department: a systematic review and narrative synthesis

BACKGROUND

Clinical guidelines are integral to a general practitioner's decision to refer a paediatric patient to emergency care. The influence of non-clinical factors must also be considered. This review explores the non-clinical factors that may influence general practitioners (GPs) when deciding whether or not to refer a paediatric patient to the Emergency Department (ED).

METHODS

A systematic review of peer-reviewed literature published from August 1980 to July 2019 was conducted to explore the non-clinical factors that influence GPs' decision-making in referring paediatric patients to the emergency department. The results were synthesised using a narrative approach.

RESULTS

Seven studies met the inclusion criteria. Non-clinical factors relating to patients, GPs and health systems influence GPs decision to refer children to the ED. GPs reported parents/ caregivers influence, including their perception of severity of child's illness, parent's request for onward referral and GPs' appraisal of parents' ability to cope. Socio-economic status, GPs' aversion to risk and system level factors such as access to diagnostics and specialist services also influenced referral decisions.

CONCLUSIONS

A myriad of non-clinical factors influence GP referrals of children to the ED. Further research on the impact of non-clinical factors on clinical decision-making can help to elucidate patterns and trends of paediatric healthcare and identify areas for intervention to utilise resources efficiently and improve healthcare delivery.