Potential role of general practice in reducing emergency department demand: A qualitative study

"I do not know the advantages of having a general practitioner" - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care

BACKGROUND

Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP.

METHOD

Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis.

RESULTS

Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity.

CONCLUSION

Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00023480; date: 2020/11/27.

Healthcare Decision-Making in a Crisis: A Qualitative Systemic Review Protocol

Background. Throughout history, communities have faced outbreaks of infectious diseases and other natural and man-made disasters that pose significant threats to lives, public health, and business continuity. Many of these disasters are crises that require critical decisions to be made in a short, crucial time with limited information and unforeseen circumstances amidst panic, fear, and shock. The COVID-19 pandemic is a recent example, with public leaders responding to and formulating strategies to attenuate the relentless waves of transmission and surges in resource demands. The pandemic underscored the importance of understanding how healthcare leaders make decisions in-crisis and what factors healthcare leaders prioritize in their decision-making process. Methods/Design. PubMed(NLM), Embase(Ovid), Scopus(Elsevier), Business Source(EBSCOhost), and ProQuest will be searched for primary qualitative studies published in English to explore the multi-faceted decision-making processes of healthcare leaders during a public health crisis. A meta-ethnographic approach will synthesize insights into healthcare leaders' experiences and perspectives and generate a conceptual theory of decision-making in crisis. Discussion. Understanding how healthcare leaders make critical decisions during public health crises takes advantage of the lessons learned to inform how future health crises are managed. (This systematic review is registered in PROSPERO: CRD42023475382).

Characteristics of patients who return unplanned to the ED, and factors that contribute to their decision to return: Integrated results from an explanatory sequential mixed methods inquiry

AIM

To identify common characteristics of patients who return to the ED unplanned and factors that may contribute to their decision to return.

BACKGROUND

Return visits to the Emergency Department (ED) have been associated with adverse events and deficits in initial care provided. There is increasing evidence to suggest that many return visits may be preventable.

METHODS

The results of primary quantitative measures (QUAN) followed by qualitative measures (qual) were integrated to build on and explain the quantitative data found in the initial phase of the research.

RESULTS

Integration of results produced three new findings. 1) Most return visits occurred beyond 48 hrs because patients intentionally delayed going back to the ED despite their persisting symptoms; 2) Clinical urgency and deterioration were rarely evident in patients who made return visits in patients and 3) Ineffective communication between the clinician and the patient at discharge may have contributed to patients making the decision to return to the ED.

CONCLUSION

The decision to return unplanned to the ED is not an immediate response for most patients, and several potentially avoidable factors may influence their decision-making process. Future research should focus on strategies which contribute to the avoidance of unplanned return visits.

Barriers Impact the Primary Healthcare Providers When Dealing With Emergency Cases: A Cross-Sectional Study in Al-Ahsa, Saudi Arabia

Introduction Being the first in-line care providers, primary healthcare (PHC) physicians may encounter all forms of medical emergencies, ranging from minor complaints to major life-threatening events; therefore, this study aims to assess the PHC physicians' knowledge and attitude related to the diagnosis and management of emergency cases as well as their preferences for emergency medicine training courses and their preferred methods of training. Methods A descriptive cross-sectional study was conducted among physicians working at PHC in Al-Ahsa, Saudi Arabia, between November and December 2023, excluding those who do not work at PHC. The minimum required sample size was 192. A self-administered online questionnaire was developed using Google Forms and distributed conveniently through social media platforms. It consists of 22 items categorized into four sections: The first section focused on demographic information; the second section assessed knowledge related to the diagnosis and management of emergency cases commonly encountered in PHC, along with actual management experiences; the third section gauged physicians' attitudes, and the fourth section explored participants' preferences for emergency medicine courses and their preferred methods of training in this field. The Kruskal-Wallis rank sum and Wilcoxon rank sum tests were employed to identify predictors of knowledge and attitude. Results The study involved 193 participants, with 96 (50%) females and a median age of 30 years. The participants included 43 (22%) consultants, 69 (36%) family residents, 30 (16%) general practitioners, and 50 (26%) specialists. Participants reported a median of 4.0 years of experience in PHC in Saudi Arabia. The majority, 69 (36%), reported working in the hospital emergency department, with a reported median duration of three months. Roughly 84% of PHC physicians had a positive attitude toward emergency cases diagnosis and management, while 92% showed fair diagnostic knowledge of emergency cases, and 73% showed fair management knowledge. Higher knowledge in the diagnosis and management of PHC was linked to increasing age, being consultants, being employed in the emergency department, and having higher years of experience in PHC (p < 0.05). A positive attitude toward PHC was found to be associated with working as a consultant and being employed in the emergency department (p < 0.05). Approximately 133 (68.9%) expressed a preference for a course in wound care trauma, followed by central nervous system emergencies (n = 124, 64.2%), coronary artery disease emergencies (n = 116, 60.1%), and obstetrics/gynecologic emergencies (n = 114, 59.1%) with 160 (82.9%) favored training through practice in PHC under supervision of qualified staff. Conclusion While many PHC centers are well equipped and prepared for early stabilization and management of emergency cases, PHC physicians showed low competency in dealing with emergency cases. This indicates a great need for enhancing physician's knowledge and skills regarding emergency situations. Nevertheless, courses like basic life support (BLS) and advanced trauma life support (ATLS) should be the bare minimum requirements for PHC physicians. Mote advance training and lectures should be organized to enhance PHC physician competencies to deal with different emergencies.

The paramedic-general practitioner relationship: a scoping review

BACKGROUND

Health services internationally are implementing programs that increase working ties between paramedics and general practitioners (GPs) to reduce unnecessary transport to emergency departments (EDs) and improve access to primary health care. As paramedic involvement in primary health care develops, there is increasing focus on the GP-paramedic collaborative relationship. Resulting issues regarding professional boundaries may occur, as paramedics practice in fields that were previously solely in the GP scope. An effective paramedic-GP working relationship will be an essential foundation to the success of future strategies.

METHODS

A search of three electronic databases was completed (Ovid MEDLINE, Embase Classic+ Embase and CINAHL Plus). Eligibility for inclusion required analysis of the relationship between paramedics and GPs. All processes were completed by two independent reviewers.

RESULTS

After removal of duplicates, 4995 titles were screened by title and/or abstract. After full-text review, 15 studies were included. Five themes were identified that contribute significantly to the strengths and weaknesses of the relationship - the importance of communication, understanding scope of practice, leadership roles, responsibility for patient care and interdisciplinary training. Issues identified included significant variation in the structure of different emergency medical services and varying standards of education requirements for paramedics worldwide.

CONCLUSIONS

There were no published Australian studies that had the primary aim of examining the paramedic-GP relationship. The depth of research on this topic is lacking, despite increased interest over the past decade. The relevance of the international literature to the Australian setting is questionable.

Exploring the views of low-acuity emergency department consulters on an educational intervention and general practitioner appointment service: a qualitative study in Berlin, Germany

OBJECTIVES

Low-acuity patients presenting to emergency departments (EDs) frequently have unmet ambulatory care needs. This qualitative study explores the patients' views of an intervention aimed at education about care options and promoting primary care (PC) attachment.

DESIGN

Qualitative telephone interviews were conducted with a subsample of participants of an interventional pilot study, based on a semi-structured interview guide. The data were analysed through qualitative content analysis.

SETTING

The study was carried out in three EDs in the city centre of Berlin, Germany.

PARTICIPANTS

Thirty-two low-acuity ED consulters with no connection to a general practitioner (GP) who had participated in the pilot study were interviewed; (f/m: 15/17; mean age: 32.9 years).

INTERVENTION

In the pilot intervention, ED patients with low-acuity complaints were provided with an information leaflet on appropriate ED usage and alternative care paths and they were offered an optional GP appointment scheduling service. Qualitative interviews explored the views of a subsample of the participants on the intervention.

RESULTS

Interviewees perceived both parts of the intervention as valuable. Receiving a leaflet about appropriate ED use and alternatives to the ED was viewed as helpful, with participants expressing the desire for additional online information and a wider distribution of the content. The GP appointment service was positively assessed by the participants who had made use of this offer and seen as potentially helpful in establishing a long-term connection to GP care. The majority of patients declining a scheduled GP appointment expected no personal need for further medical care in the near future or preferred to choose a GP independently.

CONCLUSIONS

Low-acuity ED patients seem receptive to information on alternative acute care options and prevailingly appreciate measures to encourage and facilitate attachment to a GP. Promoting PC integration could contribute to a change in future usage behaviour.

TRIAL REGISTRATION NUMBER

DRKS00023480.

A Qualitative Study of Rural and Remote Australian General Practitioners' Involvement in High-Acuity Patients

This study aimed to understand the experiences, barriers, and facilitators of rural general practitioners' involvement with high-acuity patients. Semi-structured interviews with rural general practitioners in South Australia who had experience delivering high-acuity care were audio-recorded, transcribed verbatim, and analyzed through content and thematic approaches incorporating Potter and Brough's capacity-building framework. Eighteen interviews were conducted. Barriers identified include the inability to avoid high-acuity work in rural and remote areas, pressure to handle complex presentations, lack of appropriate resources, lack of mental health support for clinicians, and impacts on social life. Enablers included a commitment to community, comradery in rural medicine, training, and experience. We concluded that general practitioners are a vital pillar of rural health service delivery and are inevitably involved in disaster and emergency response. While the involvement of rural general practitioners with high-acuity patients is complex, this study suggested that with the appropriate system, structure and role supports, rural general practitioners could be better empowered to manage high-acuity caseloads locally.

Understanding patient preferences for emergency care for lower triage acuity presentations during GP hours: a qualitative study in Australia

BACKGROUND

Low acuity presentations to Australian emergency departments drive long wait times, higher costs and may be better treated in primary care settings. This study sought to understand factors leading these patients to present to emergency departments.

METHODS

Semi-structured interviews were carried out with patients at two tertiary emergency departments in Sydney during general practitioner opening hours. Nvivo was used to code the interviews and a thematic analysis was carried out to capture the main themes from the interviews.

RESULTS

Forty-four interviews were included in the analysis across the two sites. They represented a diverse population in terms of ethnicity, education and socioeconomic background. Patient preferences for emergency care were organised into four main themes: (i) patients were referred (either by another health service, work, friend, or family), (ii) emergency department factors (convenience of investigations and severity of symptoms requiring emergency care), (iii) GP factors (does not have a GP, cannot find an appointment with a GP or has previously had a negative experience with a GP) and (iv) personal factors such as their connection to the hospital.

CONCLUSION

Multiple factors led patients to seek ED care for low acuity presentations during GP hours. Some of these factors could be addressed to meet patient needs in the community, however this is currently not the case. Addressing these factors to improve access to GP clinics and the availability of services outside the hospital setting could reduce ED presentations and likely improve patient experience.