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Davies F, Edwards M, Price D, Anderson P, Carson-Stevens A, Choudhry M, Cooke M, Dale J, Donaldson L, Evans BA, Harrington B, Harris S, Hepburn J, Hibbert P, Hughes T, Hussain F, Islam S, Pockett R, Porter A, Siriwardena AN, Snooks H, Watkins A, Edwards A, Cooper A. Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-152. [PMID: 38687611 DOI: 10.3310/jwqz5348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Background Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models. Objectives To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models. Design Mixed-methods realist evaluation. Methods Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development. Results General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models. Limitations The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored. Conclusion Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services. Future work The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy. Study registration This study is registered as PROSPERO CRD42017069741. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Freya Davies
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Delyth Price
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Bangor Institute for Health and Medical Research, Bangor University, Wales, UK
| | | | - Mazhar Choudhry
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Matthew Cooke
- Professor of Clinical Systems Design, Warwick Medical School, Warwick, UK
| | - Jeremy Dale
- Professor of Clinical Systems Design, Warwick Medical School, Warwick, UK
| | | | - Bridie Angela Evans
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Shaun Harris
- Swansea Centre for Health Economics, School of Health and Social Care, Swansea University, Swansea, UK
| | - Julie Hepburn
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | - Faris Hussain
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Saiful Islam
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Rhys Pockett
- Swansea Centre for Health Economics, School of Health and Social Care, Swansea University, Swansea, UK
| | - Alison Porter
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Helen Snooks
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | - Alan Watkins
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | - Adrian Edwards
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Alison Cooper
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
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2
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Bessert* B, Oltrogge-Abiry* JH, Peters PS, Schmalstieg-Bahr K, Bobardt-Hartshorn JS, Janis Pohontsch N, Bracht S, Mayer-Runge U, Scherer M. Synergism of an Urgent Care Walk-in Clinic With an Emergency Department. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:491-498. [PMID: 37378594 PMCID: PMC10511010 DOI: 10.3238/arztebl.m2023.0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 12/16/2022] [Accepted: 05/11/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND The overutilization of hospital emergency departments by low-urgency patients is seen as a growing problem in health-care delivery, and a variety of solutions are under discussion. We studied the change in utilization of a hospital emergency department (ED) by low-urgency patients after an urgent care walk-in clinic (WIC) was opened in the immediate vicinity. METHODS A prospective, single-center pre-post comparative study was carried out at the University Medical Center Hamburg-Eppendorf (UKE). The ED patient collective consisted of adult walk-in patients who presented to the ED between 4 pm and midnight. The "pre" period consisted of August and September 2019, and the "post" period was from November 2019 (after the opening of the WIC) to January 2020. RESULTS The study patients consisted of 4765 ED walk-in patients and 1201 WIC patients. 956 (80.5%) of the WIC patients had been referred onward to the WIC after initially presenting to the ED; from this group, 790 patients (82.6%) received definitive care in the WIC. The number of outpatients treated in the ED fell by 37.3% (95% confidence interval [30.9; 43.8]), from 851.5 to 536.7 per month. The most marked decreases were in the areas of dermatology (from 62.5 to 14.3 patients per month), neurology (45.5 to 25), ophthalmology (115 to 64.7), and trauma surgery (211 to 128.7). No decrease was seen in urology, psychiatry, or gynecology. For patients presenting without any referral document, the mean length of stay fell by a mean of 17.6 [7.4; 27.8] minutes from its "pre" value of 172.3 minutes. The rate of patients who left during treatment fell from 76.5 to 28.3 patients per month (p < 0.001). CONCLUSION A GP-led urgent care walk-in clinic next door to an interdisciplinary hospital emergency department is a resource-saving treatment option for walk-in patients who present to the emergency department. Most of the patients referred from the ED to the WIC were able to receive definitive care there.
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Affiliation(s)
- Bastian Bessert*
- *These authors share first authorship
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Germany
| | - Jan Hendrik Oltrogge-Abiry*
- *These authors share first authorship
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Germany
| | - Penelope-Sophie Peters
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Germany
| | | | | | - Nadine Janis Pohontsch
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Germany
| | - Svea Bracht
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Germany
| | - Ulrich Mayer-Runge
- Interdiscplinary Central Emergency Department, University Medical Center Hamburg-Eppendorf, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Germany
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3
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Kusters RWJ, Peters NALR, van Osch FHM, Simons PCG, Hulsbosch MHHM, Janzing HMJ, Barten DG. Primary care access to radiology: Characteristics of trauma patients referred to the emergency department. J Eval Clin Pract 2023; 29:101-107. [PMID: 35851516 PMCID: PMC10084186 DOI: 10.1111/jep.13738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 01/18/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES Low-urgent Emergency Department (ED) attendances are a known contributing factor to ED crowding. In the Netherlands, general practitioners (GPs) have direct access to radiology facilities during office hours. Patients with radiographically confirmed traumatic injuries are subsequently referred to the ED. We analysed these ED trauma patients' characteristics, provided treatments and ED discharge diagnoses to identify the possibility of alternative care pathways. METHODS Single-centre retrospective observational study of trauma patients referred to the ED by the radiology department during office hours (January 2017-December 2017). Data were obtained from patient records. Descriptive statistics were used to analyse the extracted data. RESULTS A total of 662 patients were included. The median age was 42 years (range: 1-100, interquartile range (IQR): 15-63) and patients presented to the ED with a median delay of 1 day (range: 0-112 days, IQR: 0-5). Most patients were referred for injuries involving the upper extremities (61.5%) and lower extremities (30%). A total of 48 additional diagnoses were made in the ED. The majority of injuries was classified as 'minor' (29.5%) or 'moderate' (68.3%) on the Abbreviated Injury Scale (AIS). The median length of stay in the ED was 65 min (range: 7-297 min, IQR: 43-102). CONCLUSION Most patients presented with low acuity injuries and often with a notable delay to the ED. This suggests that the majority of these patients do not necessarily need ED treatment, which may provide an opportunity to counter ED crowding.
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Affiliation(s)
- Renske W J Kusters
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | | | - Frits H M van Osch
- Department of Clinical Epidemiology, VieCuri Medical Center, Venlo, The Netherlands.,Department of Epidemiology, Maastricht University, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Petra C G Simons
- Department of Radiology, VieCuri Medical Center, Venlo, The Netherlands
| | - Mark H H M Hulsbosch
- Department of Orthopedic Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | | | - Dennis G Barten
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, The Netherlands
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4
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van der Baaren R, Barten DG, van Osch F, van Barneveld KWY, Janzing HMJ, Cals JWL. Minor traumatic injuries in the emergency department pre- and post-implementation of an emergency care access point. J Eval Clin Pract 2023; 29:32-38. [PMID: 35599366 DOI: 10.1111/jep.13705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/09/2022] [Accepted: 05/12/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE In the Netherlands, out-of-hours General Practice Cooperatives (GPCs) increasingly collaborate with Emergency Departments (EDs) to form an Emergency Care Access Point (ECAP). ECAPs aim to decrease the number of low-urgent ED attendances, of which many compromise minor traumatic injuries. In this study, we evaluated the impact of ECAP implementation on the incidence of minor traumatic injuries in the ED. METHODS We evaluated a total of 2772 ED patients who presented with a minor traumatic injury (categorized into traumatic wounds and isolated extremity injuries) 1 year before and 1 year after ECAP implementation. We compared patient characteristics, throughput, diagnosis, treatment and follow-up before and after ECAP implementation. RESULTS ECAP implementation was associated with a reduction in ED volume for minor traumatic injuries: -12.4% for isolated extremity injuries (1249 vs. 1094) and -74.6% for traumatic wounds (342 vs. 87). Multivariable logistic regression analysis controlling for patient characteristics showed that ECAP implementation was associated with higher rates of substantial injuries in the ED (OR 1.20, 95% CI = 1.01-1.43), and more patients requiring outpatient follow-up. CONCLUSION Implementation of an ECAP was associated with a reduction of ED utilization by patients with minor traumatic injuries, traumatic wounds in particular. This healthcare intervention may therefore help to reduce ED utilization for low-urgent complaints.
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Affiliation(s)
- Rens van der Baaren
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | - Dennis G Barten
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | - Frits van Osch
- Department of Clinical Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
| | | | | | - Jochen W L Cals
- Department of Family Medicine, Care and Public Health Research Institute CAPHRI, Maastricht University, Maastricht, The Netherlands
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5
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Association between acute care collaborations and health care utilization as compared to stand-alone facilities in the Netherlands: a quasi-experimental study. Eur J Emerg Med 2023; 30:15-20. [PMID: 35989654 PMCID: PMC9770117 DOI: 10.1097/mej.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Health systems invest in coordination and collaboration between emergency departments (ED) and after-hours primary care providers (AHPCs) to alleviate pressure on the acute care chain. There are substantial gaps in the existing evidence, limited in sample size, follow-up care, and costs. We assess whether acute care collaborations (ACCs) are associated with decreased ED utilization, hospital admission rates, and lower costs per patient journey, compared with stand-alone facilities. The design is a quasi-experimental study using claims data. The study included 610 845 patients in the Netherlands (2017). Patient visits in ACCs were compared to stand-alone EDs and AHPCs. The number of comorbidities was similar in both groups. Multiple logistic and gamma regressions were used to determine whether patient visits to ACCs were negatively associated with ED utilization, hospital admission rates, and costs. Logistic regression analysis did not find an association between patients visiting ACCs and ED utilization compared to patients visiting stand-alone facilities [odds ratio (OR), 1.01; 95% confidence interval (CI), 1.00-1.03]. However, patients in ACCs were associated with an increase in hospital admissions (OR, 1.07; 95% CI, 1.04-1.09). ACCs were associated with higher total costs incurred during the patient journey (OR, 1.02; 95% CI, 1.01-1.03). Collaboration between EDs and AHPCs was not associated with ED utilization, but was associated with increased hospital admission rates, and higher costs. These collaborations do not seem to improve health systems' financial sustainability.
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McFadzean IJ, Edwards M, Davies F, Cooper A, Price D, Carson-Stevens A, Dale J, Hughes T, Porter A, Harrington B, Evans B, Siriwardena N, Anderson P, Edwards A. Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'. BMC Emerg Med 2022; 22:155. [PMID: 36068508 PMCID: PMC9450363 DOI: 10.1186/s12873-022-00709-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 08/16/2022] [Indexed: 11/28/2022] Open
Abstract
Background It is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care (‘provider-induced demand’). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand. Methods We used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating ‘CMO’ configurations to develop and refine theories relating to drivers of demand. Results EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients’ experiences of accessing primary care, community care capacity, service design and population characteristics. Conclusions Patient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00709-2.
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Affiliation(s)
- I J McFadzean
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales.
| | - M Edwards
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales.
| | - F Davies
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - A Cooper
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - D Price
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - A Carson-Stevens
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - J Dale
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Warwick, UK
| | - T Hughes
- John Radcliff Hospital, Oxford, UK
| | - A Porter
- Swansea University Medical School, Swansea University, Swansea, Wales
| | - B Harrington
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - B Evans
- Swansea University Medical School, Swansea University, Swansea, Wales
| | - N Siriwardena
- School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - P Anderson
- Swansea University Medical School, Swansea University, Swansea, Wales
| | - A Edwards
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
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7
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Gilbert A, Brasseur E, Petit M, Donneau AF, D’Orio V, Ghuysen A. Advanced triage to redirect non-urgent Emergency Department visits to alternative care centers: the PERSEE algorithm. Acta Clin Belg 2022; 77:571-578. [PMID: 33856271 DOI: 10.1080/17843286.2021.1914948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Primary care treatable visits in the Emergency Department (ED) are part of the different factors leading to the overcrowding. Their triage and diversion to alternative care centers could potentially help manage the increasing inflow provided the establishment of an advanced triage to ensure patients' safety. We aim to suggest a new triage tool, PERSEE, and prove its feasibility, safety and performance. METHODS All self-referrals presented to the ED were triaged with the PERSEE algorithm: first, patients were classified with a five-level ED acuity scale and then evaluated by algorithms to determine their appropriate category (ED or Primary Care). Patients were eligible for a redirection if they were triaged by the acuity scale as level 3 or lower, considered as ambulatory patients and finally categorized as primary care patients. We defined appropriate redirections as patients requiring less than three emergency resources, no emergency-specific treatment and no hospitalization. RESULTS During the study, 1999 patients were admitted to the ED. Among those, 1333 patients were self-referred (66.9%) of whom 1167 patients were triaged as level 3 or below (58.6%) and 775 patients triaged as ambulatory (39.0%). Among the 775 patients, 200 patients were categorized as primary care treatable (10.0%) and thereby, as potentially eligible for a redirection. We noticed an error rate of 7%, sensitivity of 24.06% and specificity of 97.6%. The redirection rate reached 15% of the self-referrals. CONCLUSION These results indicate that PERSEE triage could lead to a safe redirection and could be an efficient tool to reduce ED crowding provided several adjustments.
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Affiliation(s)
- Allison Gilbert
- Emergency Department, University Hospital Center, Liège, Belgium
| | - Edmond Brasseur
- Emergency Department, University Hospital Center, Liège, Belgium
| | - Mérédith Petit
- Emergency Department, University Hospital Center, Liège, Belgium
| | - Anne Françoise Donneau
- Biostatistics Unit, University of Liège, Liège, Belgium
- Public Health Department, University of Liège, Liège, Belgium
| | - Vincent D’Orio
- Emergency Department, University Hospital Center, Liège, Belgium
| | - Alexandre Ghuysen
- Emergency Department, University Hospital Center, Liège, Belgium
- Public Health Department, University of Liège, Liège, Belgium
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8
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Feral-Pierssens AL, Morris J, Marquis M, Daoust R, Cournoyer A, Lessard J, Berthelot S, Messier A. Safety assessment of a redirection program using an electronic application for low-acuity patients visiting an emergency department. BMC Emerg Med 2022; 22:71. [PMID: 35488215 PMCID: PMC9052637 DOI: 10.1186/s12873-022-00626-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Emergency departments (EDs) are operating at or above capacity, which has negative consequences on patients in terms of quality of care and morbi-mortality. Redirection strategies for low-acuity ED patients to primary care practices are usually based on subjective eligibility criteria that sometimes necessitate formal medical assessment. Literature investigating the effect of those interventions is equivocal. The aim of the present study was to assess the safety of a redirection process using an electronic clinical support system used by the triage nurse without physician assessment. Methods A single cohort observational study was performed in the ED of a level 1 academic trauma center. All low-acuity patients redirected to nearby clinics through a clinical decision support system (February–August 2017) were included. This system uses different sets of medical prerequisites to identify patients eligible to redirection. Data on safety and patient experience were collected through phone questionnaires on day 2 and 10 after ED visit. The primary endpoint was the rate of redirected patients returning to any ED for an unexpected visit within 48 h. Secondary endpoints were the incidence of 7-day return visit and satisfaction rates. Results A total of 980 redirected low-acuity patients were included over the period: 18 patients (2.8%) returned unexpectedly to an ED within 48 h and 31 patients (4.8%) within 7 days. No hospital admission or death were reported within 7 days following the first ED visit. Among redirected patients, 81% were satisfied with care provided by the clinic staff. Conclusion The implementation of a specific electronic-guided decision support redirection protocol appeared to provide safe deferral to nearby clinics for redirected low-acuity patients. EDs are pivotal elements of the healthcare system pathway and redirection process could represent an interesting tool to improve the care to low-acuity patients.
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Affiliation(s)
- Anne-Laure Feral-Pierssens
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada. .,CR-CSIS, Sherbrooke University, Longueuil, Québec, Canada. .,Health Educations and Promotion Laboratory (LEPS EA3412), University Sorbonne Paris Nord, Bobigny, France. .,SAMU 93 - Emergency Department, Avicenne Hospital, Assistance Publique Hôpitaux de Paris, Bobigny, France.
| | - Judy Morris
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Martin Marquis
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada
| | - Raoul Daoust
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Alexis Cournoyer
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada.,Hôpital Maisonneuve-Rosemont, CIUSSS-EIM, Montréal, Québec, Canada.,Corporation d'Urgences-santé, Montréal, Québec, Canada
| | - Justine Lessard
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Simon Berthelot
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada.,Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Alexandre Messier
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
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9
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Rutten MH, Giesen PHJ, Assendelft WJJ, Westert G, Smits M. Effects of access to radiology in out-of-hours primary care on patient satisfaction and length of stay. Eur J Gen Pract 2021; 27:221-227. [PMID: 34369252 PMCID: PMC8354153 DOI: 10.1080/13814788.2021.1959911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Direct access to hospital radiology facilities by general practitioner (GP) cooperatives is known to decrease the number of emergency department referrals, but the effects on length of stay (LOS; time from patient arrival at GP cooperative till departure to home) and patient experiences are unclear. OBJECTIVES To provide insight into the LOS and experiences of trauma patients with an indication for radiology at GP cooperatives with and without access to radiology. METHODS A multi-methods observational study in April 2014-October 2015 at six GP cooperatives in The Netherlands, covering three organisational models for access to radiology: no direct access, limited access and unlimited access. Patient experiences were measured with a questionnaire. Patient records were analysed for background characteristics, radiology outcomes, referral and LOS. RESULTS In total 657 patients were included, 232 no direct access model, 307 limited access model and 118 unlimited access model. The mean LOS was 99 minutes, with a significant difference between GP cooperatives without access to radiology (121 minutes), with limited access (86 minutes), and with unlimited access (90 minutes). The differences were larger for patients without radiological abnormalities. On a ten-point scale, patients rated GP cooperatives with unlimited access to radiology higher (8.62) than those without access (8.36) or with limited access (8.39). CONCLUSION Access to radiology by GP cooperatives seems to reduce the length of stay and is slightly more appreciated by patients. GP cooperatives with unlimited access seem to provide the most efficient and best-valued care, contributing to more patient-centred care.
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Affiliation(s)
- Martijn H Rutten
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Scientific Centre for Quality of Healthcare (IQ healthcare), Nijmegen, The Netherlands
| | - Paul H J Giesen
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Scientific Centre for Quality of Healthcare (IQ healthcare), Nijmegen, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care Nijmegen, Radboud University Medical Centre, Radboud Institute for Health Sciences, The Netherlands
| | - Gert Westert
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Scientific Centre for Quality of Healthcare (IQ healthcare), Nijmegen, The Netherlands
| | - Marleen Smits
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Scientific Centre for Quality of Healthcare (IQ healthcare), Nijmegen, The Netherlands
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10
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Lehto M, Mustonen K, Raina M, Kauppila T. Differences between recorded diagnoses of patients of an emergency department and office-hours primary care doctors: a register-based study in a Finnish town. Int J Circumpolar Health 2021; 80:1935593. [PMID: 34077332 PMCID: PMC8174484 DOI: 10.1080/22423982.2021.1935593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
To determine the extent to which it is possible to provide continuity of primary care for those who visit Emergency Departments (EDs) we studied how recorded diagnoses in primary care differ, depending on whether the patient is met in an ED or a primary care office-hours practice. In the present, 12-year follow-up study a report generator of the Electronic Health Record-system provided monthly figures for the number of different recorded diagnoses using the International Classification of Diagnoses (10thedition, ICD-10) and the total number of ED doctors and office-hour visits to General Practitioners (GPs). The 20 most common diagnoses covered 48.1% of the visits with recorded diagnoses to the office hour GPs and 45.9% of the visits to the doctors of the ED. Of these 20 diagnoses, 10 were common in both systems. These 10 diagnoses constituted about 30% of the diagnoses given by ED doctors. Furthermore, five out of the six most common diagnoses were the same in the ED and office-hours practices. The doctors in EDs and office-hour GPs treat quite similar patient material. This may provide organisational ways to reorganise the work of primary care and to guarantee continuity of care for those who may benefit from it.
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Affiliation(s)
- Mika Lehto
- City of Vantaa, Vantaa, Finland.,Department of General Practice, University of Helsinki, Helsinki, Finland
| | - Katri Mustonen
- Department of General Practice, University of Helsinki, Helsinki, Finland
| | | | - Timo Kauppila
- Department of General Practice, University of Helsinki, Helsinki, Finland.,Department of Oral and Maxillofacial Diseases, Head and Neck Center, University of Helsinki, Helsinki, Finland.,Department of General Practice, University of Tampere, Tampere, Finland
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11
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Abstract
Introduction In response to emergency department over-crowding primary care practitioners (PCPs) have been incorporated into care pathways to provide integrated care. We consider why a pilot project of PCP-led streaming in a German emergency department failed, the challenges encountered transplanting models between differing systems and cultures, and if the concept constitutes integrated care. Theory and Methods The original design was a mixed methods data gather around PCP-streaming of non-urgent self-referrers in an emergency department. Results The demand for the PCP-streaming was low, which was at odds with pre-study estimates. The study was stopped prematurely without adequate data; this is an opinion-based article. Discussion A fundamental of emergency care is a central emergency department. An emergency department can be the fulcrum from which urgent inter-disciplinary hospital care is initiated and coordinated. Objective triage is fundamental to this and regional healthcare planning. With such fundamentals in place, PCP integration has the potential to facilitate and provide integrated care. Relevant elements of the Rainbow Model of Integrated Care frame the discussion. Conclusion The key element deficient in each barrier to our project, yet present in successful studies, was normative integration.
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12
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Holzinger F, Oslislo S, Möckel M, Schenk L, Pigorsch M, Heintze C. Self-referred walk-in patients in the emergency department - who and why? Consultation determinants in a multicenter study of respiratory patients in Berlin, Germany. BMC Health Serv Res 2020; 20:848. [PMID: 32912185 PMCID: PMC7481545 DOI: 10.1186/s12913-020-05689-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/26/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Emergency department (ED) consultations are on the rise, and frequently consultations by non-urgent patients have been held accountable. Self-referred walk-in (SRW) consulters supposedly represent a predominantly less urgent patient population. The EMACROSS study aimed to explore consultation determinants and motives in SRW patients with respiratory symptoms. METHODS Multicenter survey of adult ED patients with respiratory complaints in eight emergency departments in central Berlin, Germany. Secondary hospital records data including diagnoses was additionally assessed. Characteristics of SRW and non-SRW patients were compared. Determinants of SRW consultation were evaluated by binary logistic regression. Consultation motives were analyzed descriptively. As a supplemental approach, network analysis (lasso-regularized mixed graphical model) was performed to explore connections between consultation determinants, consultation features and motives. RESULTS Between June 2017 and November 2018, n = 472 participants were included, the median age was 55 years (range 18-96), 53.2% of patients were male and n = 185 cases (39.2%) were SRW consulters. The SRW group showed lower proportions of potentially severe (pneumonia and respiratory failure, p < 0.001, χ2 test) and chronic pulmonary conditions. Determinants of SRW consultation identified by logistic regression were younger age (p < 0.001), tertiary education (p = 0.032), being a first-generation migrant (p = 0.002) or tourist (p = 0.008), having no regular primary care provider (p = 0.036) and no chronic pulmonary illness (p = 0.017). The area under the curve (AUC) for the model was 0.79. Personal distress and access problems in ambulatory care were stated most frequently as consultation motives in the SRW group; network analysis showed the scarcity of associations between demographic and medical SRW determinants and motives triggering the actual decision to consult. CONCLUSIONS As to "who" consults, this study identified demographic and medical predictors of SRW utilization. The said markers seem only remotely connected to "why" people decide for SRW visits. To alleviate ED crowding by addressing frequent SRW consultation motives, interventions focused on the ability for symptom self-assessment and at better-accessible alternative care seem sensible. TRIAL REGISTRATION German Clinical Trials Register ( DRKS00011930 ); date: 2017/04/25.
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Affiliation(s)
- Felix Holzinger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany.
| | - Sarah Oslislo
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Möckel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Division of Emergency Medicine, Berlin, Germany
- The College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
| | - Liane Schenk
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany
| | - Mareen Pigorsch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Christoph Heintze
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany
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13
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Edwards M, Cooper A, Davies F, Sherlock R, Carson-Stevens A, Price D, Porter A, Evans B, Islam S, Snooks H, Anderson P, Siriwardena AN, Hibbert P, Hughes T, Cooke M, Dale J, Edwards A. Emergency department clinical leads' experiences of implementing primary care services where GPs work in or alongside emergency departments in the UK: a qualitative study. BMC Emerg Med 2020; 20:62. [PMID: 32799820 PMCID: PMC7429882 DOI: 10.1186/s12873-020-00358-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 08/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To manage increasing demand for emergency and unscheduled care NHS England policy has promoted services in which patients presenting to Emergency Departments (EDs) with non-urgent problems are directed to general practitioners (GPs) and other primary care clinicians working within or alongside emergency departments. However, the ways that hospitals have implemented primary care services in EDs are varied. The aim of this study was to describe ED clinical leads' experiences of implementing and delivering 'primary care services' and 'emergency medicine services' where GPs were integrated into the ED team. METHODS We conducted interviews with ED clinical leads in England (n = 19) and Wales (n = 2). We used framework analysis to analyse interview transcripts and explore differences across 'primary care services', 'emergency medicine services' and emergency departments without primary care services. RESULTS In EDs with separate primary care services, success was reported when having a distinct workforce of primary care clinicians, who improved waiting times and flow by seeing primary care-type patients in a timely way, using fewer investigations, and enabling ED doctors to focus on more acutely unwell patients. Some challenges were: trying to align their service with the policy guidance, inconsistent demand for primary care, accessible community primary care services, difficulties in recruiting GPs, lack of funding, difficulties in agreeing governance protocols and establishing effective streaming pathways. Where GPs were integrated into an ED workforce success was reported as managing the demand for both emergency and primary care and reducing admissions. CONCLUSIONS Introducing a policy advocating a preferred model of service to address primary care demand was not useful for all emergency departments. To support successful and sustainable primary care services in or alongside EDs, policy makers and commissioners should consider varied ways that GPs can be employed to manage variation in local demand and also local contextual factors such as the ability to recruit and retain GPs, sustainable funding, clear governance frameworks, training, support and guidance for all staff. Whether or not streaming to a separate primary care service is useful also depended on the level of primary care demand.
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Affiliation(s)
- Michelle Edwards
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK.
| | - Alison Cooper
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK
| | - Freya Davies
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK
| | - Rebecca Sherlock
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK
| | | | - Delyth Price
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK
| | - Alison Porter
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Bridie Evans
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Saiful Islam
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Helen Snooks
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Pippa Anderson
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | | | - Peter Hibbert
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Macquarie Park, Australia
| | - Thomas Hughes
- Emergency Department, John Radcliffe Hospital, Oxford, UK
| | - Matthew Cooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jeremy Dale
- Academic Primary Care, Warwick University, Coventry, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK
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Ellbrant J, Åkeson J, Sletten H, Eckner J, Karlsland Åkeson P. Adjacent Primary Care May Reduce Less Urgent Pediatric Emergency Department Visits. J Prim Care Community Health 2020; 11:2150132720926276. [PMID: 32501136 PMCID: PMC7278310 DOI: 10.1177/2150132720926276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims: Pediatric emergency department (ED) overcrowding is a challenge. This study was designed to evaluate if a hospital-integrated primary care unit (HPCU) reduces less urgent visits at a pediatric ED. Methods: This retrospective cross-sectional study was carried out at a university hospital in Sweden, where the HPCU, open outside office hours, had been integrated next to the ED. Children seeking ED care during 4-week high- and low-load study periods before (2012) and after (2015) implementation of the HPCU were included. Information on patient characteristics, ED management, and length of ED stay was obtained from hospital data registers. Results: In total, 3216 and 3074 ED patient visits were recorded in 2012 and 2015, respectively. During opening hours of the HPCU, the proportions of pediatric ED visits (28% lower; P < .001), visits in the lowest triage group (36% lower; P < .001), patients presenting with fever (P = .001) or ear pain (P < .001), and nonadmitted ED patients (P = .033), were significantly lower in 2015 than in 2012, whereas the proportion of infants ≤3 months was higher in 2015 (P < .001). Conclusions: By enabling adjacent management of less urgent pediatric patients at adequate lower levels of medical care, implementation of a HPCU outside office hours may contribute to fewer and more appropriate pediatric ED visits.
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Affiliation(s)
- Julia Ellbrant
- Department of Clinical Scienses Malmö, Pediatrics and Anesthesiology and Intensive Care Medicine, Lund University, Malmö, Sweden
| | - Jonas Åkeson
- Department of Clinical Scienses Malmö, Pediatrics and Anesthesiology and Intensive Care Medicine, Lund University, Malmö, Sweden
| | - Helena Sletten
- Department of Clinical Scienses Malmö, Pediatrics and Anesthesiology and Intensive Care Medicine, Lund University, Malmö, Sweden
| | - Jenny Eckner
- Department of Clinical Scienses Malmö, Pediatrics and Anesthesiology and Intensive Care Medicine, Lund University, Malmö, Sweden
| | - Pia Karlsland Åkeson
- Department of Clinical Scienses Malmö, Pediatrics and Anesthesiology and Intensive Care Medicine, Lund University, Malmö, Sweden
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15
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Cooper A, Davies F, Edwards M, Anderson P, Carson-Stevens A, Cooke MW, Donaldson L, Dale J, Evans BA, Hibbert PD, Hughes TC, Porter A, Rainer T, Siriwardena A, Snooks H, Edwards A. The impact of general practitioners working in or alongside emergency departments: a rapid realist review. BMJ Open 2019; 9:e024501. [PMID: 30975667 PMCID: PMC6500276 DOI: 10.1136/bmjopen-2018-024501] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 12/14/2018] [Accepted: 01/24/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%-43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are 'free to care for the sickest patients'. However, the research evidence to support this initiative is weak. DESIGN Rapid realist literature review. SETTING Emergency departments. INCLUSION CRITERIA Articles describing general practitioners working in or alongside emergency departments. AIM To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system. RESULTS Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes. CONCLUSIONS Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research. PROSPERO REGISTRATION NUMBER CRD42017069741.
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Affiliation(s)
- Alison Cooper
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Freya Davies
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Centre for Health Economics, Swansea University, Swansea, UK
| | | | | | - Liam Donaldson
- London School of Hygiene and Tropical Medicine, London, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Peter D Hibbert
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Thomas C Hughes
- Emergency Department, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Alison Porter
- College of Medicine, Swansea University, Swansea, UK
| | - Tim Rainer
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | - Helen Snooks
- College of Medicine, Swansea University, Swansea, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
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16
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Oslislo S, Heintze C, Schmiedhofer M, Möckel M, Schenk L, Holzinger F. How to decide adequately? Qualitative study of GPs' view on decision-making in self-referred and physician-referred emergency department consultations in Berlin, Germany. BMJ Open 2019; 9:e026786. [PMID: 30944138 PMCID: PMC6500203 DOI: 10.1136/bmjopen-2018-026786] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Patients with acute symptoms present not only to general practitioners (GPs), but also frequently to emergency departments (EDs). Patients' decision processes leading up to an ED self-referral are complex and supposed to result from a multitude of determinants. While they are key providers in primary care, little is known about GPs' perception of such patients. This qualitative study explores the GPs' view regarding motives and competences of patients self-referring to EDs, and also GPs' rationale for or against physician-initiated ED referrals. DESIGN Qualitative study with semi-structured, face-to-face interviews; qualitative content analysis. SETTING GP practices in Berlin, Germany. PARTICIPANTS 15 GPs (female/male: 9/6; mean age 53.6 years). RESULTS The interviewed GPs related a wide spectrum of factors potentially influencing their patients' decision to visit an ED, and also their own decision-making in potential referrals. Considerations go beyond medical urgency. Statements concerning patients' surmised rationale corresponded to GPs' reasoning in a variety of important areas. For one thing, the timely availability of an extended spectrum of diagnostic and therapeutic options may make ED services attractive to both. Access difficulties in the ambulatory setting were mentioned as additional triggers for an ED visit initiated by a patient or a GP. Key patient factors like severity of symptoms and anxiety also play a major role; a desire for reassurance may lead to both self-referred and physician-initiated ED visits. Patients' health competence was prevailingly depicted as limited, with the internet as an important influencing factor. Counselling efforts by GP were described as crucial for improving health literacy. CONCLUSIONS Health education could hold promise when aiming to reduce non-urgent ED consultations. Primary care providers are in a key position here. Amelioration of organisational shortages in ambulatory care, for example, limited consultation hours, might also make an important impact, as these trigger both self-referrals and GP-initiated ED referrals. TRIAL REGISTRATION NUMBER DRKS00011930.
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Affiliation(s)
- Sarah Oslislo
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
| | - Christoph Heintze
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
| | - Martina Schmiedhofer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Division of Emergency Medicine, Berlin, Germany
| | - Martin Möckel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Division of Emergency Medicine, Berlin, Germany
- James Cook University, The College of Public Health, Medical and Veterinary Sciences, Townsville, Queensland, Australia
| | - Liane Schenk
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany
| | - Felix Holzinger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
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17
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Platter MEM, Kurvers RAJ, Janssen L, Verweij MMJ, Barten DG. The impact of an emergency care access point on pediatric attendances at the emergency department: An observational study. Am J Emerg Med 2019; 38:191-197. [PMID: 30745074 DOI: 10.1016/j.ajem.2019.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 02/03/2019] [Accepted: 02/03/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Crowding is a growing concern in general and pediatric Emergency Departments (EDs). The Emergency Care Access Point (ECAP) - a collaboration between general practitioners and the ED - has been established to reduce the number of self-referrals and non-urgent ED visits. The aim of this study was to determine the impact of an ECAP on pediatric attendances in the ED. METHODS Retrospective analysis of 3997 pediatric patients who visited the ED of a regional teaching hospital in the Netherlands, one year before and one year after the implementation of an ECAP. Patient characteristics, presented complaints and diagnoses, throughput times, and follow-up between the study groups were compared, both during office hours and after-hours. RESULTS After ECAP implementation, a 16.3% reduction in pediatric ED visits was observed. ECAP implementation was associated with a decline in self-referrals by 97.2%. Presented complaints, ED diagnoses and acuity were similar pre- and post-ECAP. However, consultations and follow-up were required more frequently. The admission rate during nights increased (49.3% versus 64.0%). Overall admission rates were similar. CONCLUSIONS The implementation of an ECAP was associated with a reduction of pediatric ED use, including a considerable but expected decline in pediatric self-referrals. Patient acuity pre- and post-ECAP was similar. Our results suggest that this primary care intervention might help reduce the workload in a pediatric ED. Future studies are warranted to further investigate this hypothesis and to evaluate the impact of an ECAP in other healthcare settings. These future efforts need to include patient oriented outcomes.
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Affiliation(s)
- Mireille E M Platter
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, the Netherlands; Department of Pediatrics, VieCuri Medical Center, Venlo, the Netherlands
| | - Roel A J Kurvers
- Department of Pediatrics, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Loes Janssen
- Department of Epidemiology, VieCuri Medical Center, Venlo, the Netherlands
| | | | - Dennis G Barten
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, the Netherlands.
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18
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Ellbrant J, Åkeson J, Eckner J, Karlsland Åkeson P. Influence of social characteristics on use of paediatric emergency care in Sweden - a questionnaire based study. BMC Emerg Med 2018; 18:59. [PMID: 30587134 PMCID: PMC6307227 DOI: 10.1186/s12873-018-0210-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 12/06/2018] [Indexed: 11/28/2022] Open
Abstract
Background Parental social characteristics influence the use of emergency departments (ED) in the USA, but less is known about paediatric ED care-seeking in countries with national health insurance. This prospective study was designed to evaluate associations between parental care-seeking and social characteristics, with emphasis on impact of non-native origin, at a paediatric ED in Sweden, a European country providing paediatric healthcare free of charge. Methods Parents attending a paediatric ED at a large urban university hospital filled out a questionnaire on social characteristics and reasons for care-seeking. Information on patient characteristics and initial management was obtained from ED registers and patient records. Paediatric ED physicians assessed the medical appropriateness of each patient visit triaged for ED care. Results In total, 962 patient visits were included. Telephone healthline service before the paediatric ED visit was less often used by non-native parents (63/345 vs. 249/544, p < 0.001). Low-aquity visits, triaged away from the ED, were more common among non-native parents (80/368 vs. 67/555, OR = 1.66; p = 0.018), and among those reporting lower abilities in the Swedish language (23/82 vs. 120/837, OR = 2.66; p = 0.003). Children of non-native parents were more often assessed by physicians not to require ED care (122/335 vs. 261/512, OR = 0.70; p = 0.028). Conclusions This study confirms more direct and less urgent use of paediatric ED care by parents of non-native origin or with limited abilities in the Swedish language, proposing that parental social characteristics influence paediatric ED care-seeking, also in a country with healthcare free of charge, and that specific needs of these groups should be better met by prehospital medical services. Electronic supplementary material The online version of this article (10.1186/s12873-018-0210-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julia Ellbrant
- Department of Clinical Sciences Malmö, Anaesthesiology and Intensive Care Medicine, Lund University, Skåne University Hospital, SE-20502, Malmö, Sweden. .,Department of Clinical Sciences Malmö, Surgery, Lund University, Skåne University Hospital, Jan Waldenströms gata 11 A, SE-20502, Malmö, Sweden.
| | - Jonas Åkeson
- Department of Clinical Sciences Malmö, Anaesthesiology and Intensive Care Medicine, Lund University, Skåne University Hospital, SE-20502, Malmö, Sweden
| | - Jenny Eckner
- Department of Clinical Sciences Malmö, Surgery, Lund University, Skåne University Hospital, Jan Waldenströms gata 11 A, SE-20502, Malmö, Sweden
| | - Pia Karlsland Åkeson
- Department of Clinical Sciences Malmö, Paediatrics, Lund University, Skåne University Hospital, SE-20502, Malmö, Sweden
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Abstract
OBJECTIVE Emergency Departments and out-of-hours General Practitioner services collaborate increasingly in Urgent Care Collaborations (UCCs) by sharing one combined entrance and joint triage. The aim of this study is to examine the difference between UCCs and providers who operate separately with respect to the efficiency of patient flow. METHODS This study had a cross-sectional observational design comparing three regions with UCC with three regions with usual care. Outcome measures were efficiency of patient flow, defined as a reducing length of stay (LOS), waiting time (WT) and the mean number of handovers. Data were obtained from electronic medical records. RESULTS LOS (median 34:00 vs. 38:52 min) and WT (median 14:00 vs. 18:43 min) were statistically significantly longer in UCCs compared with usual care. This difference is mainly explained by the prolonged LOS and WT for consulting a General Practitioner. The mean number of interunit handovers was larger in UCCs. CONCLUSION The results indicate that, on average, UCCs do not enhance the efficiency of patient flow. The median LOS and WT are longer in UCCs and more handovers occur in UCCs compared with usual care.
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20
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Rutten MH, Smits M, Peters YAS, Assendelft WJJ, Westert GP, Giesen PHJ. Effects of access to radiology in out-of-hours primary care in the Netherlands: a prospective observational study. Fam Pract 2018; 35:253-258. [PMID: 29029061 DOI: 10.1093/fampra/cmx093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the Netherlands, out-of-hours primary care is provided in general-practitioner-cooperatives (GPCs). These are increasingly located on site with emergency departments (ED), forming Emergency-Care-Access-Points (ECAP). A more efficient and economical organization of out-of-hours primary emergency care could be realized by increased collaboration at an ECAP. In this study, we compared the effects of different models with respect to access to (hospital) radiology by the GPC. We investigated patient and care characteristics, indication for diagnostics and outcomes at GPCs with and without access to radiology. METHODS A prospective observational record review study of patients referred for conventional radiology for trauma by one of five GPCs in the period April 2014-October 2015, covering three organizational models. RESULTS The mean age was 31 years and 56% was female. Extremities were predominately involved (91%). There was a medical indication for radiology in 85% and the assessed risk by requesting GPs on abnormalities was high in 66%. There was a significant difference in outcomes between models. Radiological abnormalities (fractures/luxations) were present in 51% without direct access and in 35% with partial and unlimited access. Overall, 61% of the included patients were referred to the ED; 100% in the models without access and 38% in the models with (partial) access. CONCLUSIONS GPC access to radiology is beneficial for patients and professionals. The diagnostics were adequately used. With access to radiology, unnecessary referrals and specialist care are prevented. This may lead to a decrease in ED attendance and overcrowding.
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Affiliation(s)
- Martijn Hendrik Rutten
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
| | - Marleen Smits
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
| | - Yvonne Anthonia Sebastiana Peters
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
| | | | - Gert Pieter Westert
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
| | - Paul Hendrikus Josephus Giesen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
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21
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van den Bersselaar D, Maas M, Thijssen W. Does X-ray imaging by GPC at emergency care access points in the Netherlands change patient flow and reduce ED crowding? A cohort study. Health Sci Rep 2018; 1:e26. [PMID: 30623058 PMCID: PMC6266461 DOI: 10.1002/hsr2.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 12/04/2017] [Accepted: 01/09/2018] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Organizing out-of-hours emergency care is a challenge in many countries. In the Netherlands, general practitioner cooperatives (GPCs) and emergency departments (EDs) are increasingly working together, creating one emergency care access point (ECAP). This has redirected the majority of patients with musculoskeletal problems from the ED to the GPC in out-of-hours care, due to the treatment of self-referrals by the general practitioner (GP). Only a minority of the GPs at ECAPs have the possibility to request X-rays, and expanding these facilities could reduce patient presentations to the ED even more. The aim of our study was to explore patient flow and possible reductions in ED referrals at an ECAP with X-ray facilities for GPs. METHODS This retrospective cohort study examines all patients that visited an ECAP at a general city hospital in the Netherlands and had an X-ray imaging requested by the GPC between January 1, 2014 and December 31, 2014. General practitioner cooperatives could request X-rays between 5 pm and 10 pm on weekdays and between 8 am and 10 pm during weekends. Recorded data included sex, age, number and type of X-ray, X-ray abnormalities, referral to the ED, and treatment. The annual number of patients presenting to the GPC and ED in 2014 were gathered. Patient outcome was stated negative when the X-ray revealed no abnormality. RESULTS A total of 2243 patients received 2663 X-ray examinations. The mean age was 31 years and 48% was male. A total of 1517 (68%) patients were treated at the GPC without an ED referral, a reduction of 4.5% of the annual ED patients. CONCLUSIONS With a majority (68%) of the patients examined and treated at the GPC, X-ray facilities at ECAPs will substantially reduce ED population, change patient flow, and have a positive effect on ED crowding. Implementing 24/7 X-ray facilities at all ECAPs will further enhance these effects.
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Affiliation(s)
| | - M. Maas
- Catharina HospitalEindhoventhe Netherlands
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22
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van der Biezen M, Wensing M, Poghosyan L, van der Burgt R, Laurant M. Collaboration in teams with nurse practitioners and general practitioners during out-of-hours and implications for patient care; a qualitative study. BMC Health Serv Res 2017; 17:589. [PMID: 28830410 PMCID: PMC5568365 DOI: 10.1186/s12913-017-2548-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 08/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasingly, nurse practitioners (NPs) are deployed in teams along with general practitioners (GPs) to help meet the demand for out-of-hours care. The purpose of this study was to explore factors influencing collaboration between GPs and NPs in teams working out-of-hours. METHODS A descriptive qualitative study was done using a total of 27 semi-structured interviews and two focus group discussions. Data was collected between June, 2014 and October, 2015 at an out-of-hours primary care organisation in the Netherlands. Overall, 38 health professionals (GPs, NPs, and support staff) participated in the study. The interviews were audio-taped and transcribed verbatim. Two researchers conducted an inductive content analysis, involving the identification of relevant items in a first phase and clustering into themes in a second phase. RESULTS The following four themes emerged from the data: clarity of NP role and regulation, shared caseload and use of skills, communication concerning professional roles, trust and support in NP practice. Main factors influencing collaboration between GPs and NPs included a lack of knowledge regarding the NPs' scope of practice and regulations governing NP role; differences in teams in sharing caseload and using each other's skills effectively; varying support of GPs for the NP role; and limited communication between GPs and NPs regarding professional roles during the shift. Lack of collaboration was perceived to result in an increased risk of delay for patients who needed treatment from a GP, especially in teams with more NPs. Collaboration was not perceived to improve over time as teams varied across shifts. CONCLUSION In out-of-hours primary care teams constantly change and team members are often unfamiliar with each other or other's competences. In this environment, knowledge and communication about team members' roles is continuously at stake. Especially in teams with more NPs, team members need to use each other's skills to deliver care to all patients on time.
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Affiliation(s)
- Mieke van der Biezen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, IQ Healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, IQ Healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Health Services Research and Implementation Science, Heidelberg University, Marsilius Arkaden-Turm West, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Lusine Poghosyan
- Columbia University School of Nursing, 168th St., Suite 219, New York, NY 10032 USA
| | - Regi van der Burgt
- Foundation for Development of Quality Care in General Practice, Tilburgseweg-West 100, 5652 NP, Eindhoven, The Netherlands
| | - Miranda Laurant
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, IQ Healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
- HAN University of Applied Sciences, Faculty of Health and Social Studies, P.O. BOX 6960, Nijmegen, 6503 GL The Netherlands
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23
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Kraaijvanger N, Rijpsma D, Willink L, Lucassen P, van Leeuwen H, Edwards M. Why patients self-refer to the Emergency Department: A qualitative interview study. J Eval Clin Pract 2017; 23:593-598. [PMID: 27976472 DOI: 10.1111/jep.12680] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 10/27/2016] [Accepted: 10/27/2016] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES There have been multiple studies investigating reasons for patients to self-refer to the Emergency Department (ED). The majority made use of questionnaires and excluded patients with urgent conditions. The goal of this qualitative study is to explore what motives patients have to self-refer to an ED, also including patients in urgent triage categories. METHODS In a large teaching hospital in the Netherlands, a qualitative interview study focusing on reasons for self-referring to the ED was performed. Self-referred patients were included until no new reasons for attending the ED were found. Exclusion criteria were as follows: not mentally able to be interviewed or not speaking Dutch. Patients who were in need of urgent care were treated first, before being asked to participate. Interviews followed a predefined topic guide. Practicing cyclic analysis, the interview topic guide was modified during the inclusion period. Interviews were recorded on an audio recorder, transcribed verbatim, and anonymized. Two investigators independently coded the information and combined the codes into meaningful clusters. Subsequently, these were categorized into themes to build a framework of reasons for self-referral to the ED. Characteristic quotes were used to illustrate the acquired theoretical framework. RESULTS Thirty self-referred patients were interviewed. Most of the participants were male (63%), with a mean age of 46 years. Two main themes emerged from the interviews that are pertinent to the patients' decisions to attend the ED: (1) health concerns and (2) practical issues. CONCLUSIONS This study found that there are 2 clearly distinctive reasons for self-referral to the ED: health concerns or practical motives. Self-referral because of practical motives is probably most suitable for strategies that aim to reduce inappropriate ED visits.
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Affiliation(s)
| | - Douwe Rijpsma
- Emergency Department, Rijnstate Hospital, Arnhem, The Netherlands
| | - Lisa Willink
- Emergency Department, Rijnstate Hospital, Arnhem, The Netherlands
| | - Peter Lucassen
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Henk van Leeuwen
- Intensive Care/Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Michael Edwards
- Surgery Department, Radboud University Medical Centre, Nijmegen, The Netherlands
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24
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Rutten M, Vrielink F, Smits M, Giesen P. Patient and care characteristics of self-referrals treated by the general practitioner cooperative at emergency-care-access-points in the Netherlands. BMC FAMILY PRACTICE 2017; 18:62. [PMID: 28499354 PMCID: PMC5429563 DOI: 10.1186/s12875-017-0633-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 05/02/2017] [Indexed: 11/10/2022]
Abstract
Background In the Netherlands, out-of-hours primary care is provided in general practitioner-cooperatives (GPCs). These are increasingly located on site and in collaboration with emergency departments of hospitals (ED). At such sites, also called emergency-care-access-points (ECAP), the GPC is generally responsible for the triage and treatment of self-referrals who used to attend the ED. To evaluate the effects and safety of this novel organisation, we studied the characteristics and the quality of care given by GPCs to self-referrals at ECAPs. Methods Retrospective analysis (August 2011–January 2012) of 783 records of self-referred patients at three Dutch GPCs in an ECAP. This was supplemented with a retrospective analysis of patient records during a follow-up period of three-months to asses safety. Results Patient-characteristics: 59% was male, 46% aged between 16–45 years and 59% trauma-related. Most cases (95%) were triaged low-urgent. None received the highest urgency-category. Quality: The triage outcome was correct in 79%, underestimated in 12% and overestimated in 9%. After GP consultation 20% were referred to the ED, mostly for radio-diagnostics. Of the referrals to secondary care, 98% were according to common medical practice. Thirty percent had a follow-up contact, mostly with their own general practitioner, seldom with the ED. Complications, all non-severe, were registered in 3.2%; 0.4% were possibly preventable. Conclusions Self-referred patients at an ECAP are mostly trauma related, low-urgent and male patients. The majority could be treated by the GPC without subsequent referral to the ED. Care given at the GPC is reasonably efficient and safe. Triage and treatment of self-referrals by the GPC at ECAPs might offer opportunities for other countries facing problems with inappropriate emergency department visits.
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Affiliation(s)
- Martijn Rutten
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
| | - Fieke Vrielink
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Marleen Smits
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Paul Giesen
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
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25
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Gabrielian S, Chen JC, Minhaj BP, Manchanda R, Altman L, Koosis E, Gelberg L. Feasibility and Acceptability of a Colocated Homeless-Tailored Primary Care Clinic and Emergency Department. J Prim Care Community Health 2017; 8:338-344. [PMID: 28367682 PMCID: PMC5932723 DOI: 10.1177/2150131917699751] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives: Homeless adults have low primary care engagement and high emergency department (ED) utilization. Homeless-tailored, patient-centered medical homes (PCMH) decrease this population’s acute care use. We studied the feasibility (focused on patient recruitment) and acceptability (conceptualized as clinicians’ attitudes/beliefs) of a pilot initiative to colocate a homeless-tailored PCMH with an ED. After ED triage, low-acuity patients appropriate for outpatient care were screened for homelessness; homeless patients chose between a colocated PCMH or ED visit. Methods: To study feasibility, we captured (from May to September 2012) the number of patients screened for homelessness, positive screens, unique patients seen, and primary care visits. We focused on acceptability to ED clinicians (physicians, nurses, social workers); we sent a 32-item survey to ED clinicians (n = 57) who worked during clinic hours. Questions derived from an instrument measuring clinician attitudes toward homeless persons; acceptability of homelessness screening and the clinic itself were also explored. Results: Over the 5 months of interest, 281 patients were screened; 172 (61.2%) screened positive for homelessness; 112 (65.1%) of these positive screens were seen over 215 visits. Acceptability data were obtained from 56% (n = 32) of surveyed clinicians. Attitudes toward homeless patients were similar to prior studies of primary care physicians. Most (54.6%) clinicians agreed with the homelessness screening procedures. Nearly all (90.3%) clinicians supported expansion of the homeless-tailored clinic; a minority (42.0%) agreed that ED colocation worked well. Conclusion: Our data suggest the feasibility of recruiting patients to a homeless-tailored primary care clinic colocated with the ED; however, the clinic’s acceptability was mixed. Future quality improvement work should focus on tailoring the clinic to increase its acceptability among ED clinicians, while assessing its impact on health, housing, and costs.
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Affiliation(s)
- Sonya Gabrielian
- 1 VA Greater Los Angeles, Los Angeles, CA, USA.,2 UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Jennifer C Chen
- 2 UCLA David Geffen School of Medicine, Los Angeles, CA, USA.,3 Harbor-UCLA Medical Center, Torrance, CA, USA
| | | | | | - Lisa Altman
- 1 VA Greater Los Angeles, Los Angeles, CA, USA.,2 UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ella Koosis
- 1 VA Greater Los Angeles, Los Angeles, CA, USA
| | - Lillian Gelberg
- 1 VA Greater Los Angeles, Los Angeles, CA, USA.,2 UCLA David Geffen School of Medicine, Los Angeles, CA, USA.,6 UCLA Fielding School of Public Health, Los Angeles, CA, USA
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26
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Colliers A, Remmen R, Streffer ML, Michiels B, Bartholomeeusen S, Monsieurs KG, Goris J, Coenen S, Verhoeven V, Philips H. Implementation of a general practitioner cooperative adjacent to the emergency department of a hospital increases the caseload for the GPC but not for the emergency department. Acta Clin Belg 2017; 72:49-54. [PMID: 27748165 DOI: 10.1080/17843286.2016.1245936] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The implementation of general practitioner cooperatives (GPC) for out-of-hours (OOH) primary care, raises the question if the location of a GPC adjacent to a hospital reduces the OOH caseload of the emergency department (ED). METHODS Two natural experiments were used in this before-after study, the effect of the implementation of two GPCs in two different regions on the out-of-hours caseload of the local EDs was compared. One GPC was located adjacent to the ED of a general hospital, the other was not. GPCs (or rota systems) and EDs in comparable regions were selected as control groups during the same study period. The study was performed in Flanders (Belgium) with no gatekeeping function for general practitioners (GPs). RESULTS After implementation of the GPC there was a significantly increase in caseload at the GPC in the two regions, mainly due to an increase of consultations with small children. There were no significant changes in caseload at the ED services. Self-referrals' to the ED did not change significantly. For the GPs the number of home visits decreased during out-of-hours in one region. CONCLUSION In a country with no gatekeeping role for GPs, implementing a GPC increased the out-of-hours caseload of the GPCs. The caseload of the EDs stabilised during the study period.
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Affiliation(s)
- Annelies Colliers
- Faculty of Medicine and Health Sciences, Department of General Practice – Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Roy Remmen
- Faculty of Medicine and Health Sciences, Department of General Practice – Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Marie-Luise Streffer
- Faculty of Medicine and Health Sciences, Department of General Practice – Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Barbara Michiels
- Faculty of Medicine and Health Sciences, Department of General Practice – Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Stefaan Bartholomeeusen
- Faculty of Medicine and Health Sciences, Department of General Practice – Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Koenraad G. Monsieurs
- Faculty of Medicine and Health Sciences, Department of General Practice – Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
- Emergency Department, Antwerp University Hospital, Edegem, Belgium
| | - Jef Goris
- General Practice Cooperative Antwerp North, Merksem, Belgium
| | - Samuel Coenen
- Faculty of Medicine and Health Sciences, Department of General Practice – Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Veronique Verhoeven
- Faculty of Medicine and Health Sciences, Department of General Practice – Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Hilde Philips
- Faculty of Medicine and Health Sciences, Department of General Practice – Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
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27
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Kraaijvanger N, van Leeuwen H, Rijpsma D, Edwards M. Motives for self-referral to the emergency department: a systematic review of the literature. BMC Health Serv Res 2016; 16:685. [PMID: 27938366 PMCID: PMC5148909 DOI: 10.1186/s12913-016-1935-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 12/06/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND In several western countries patients' use of Emergency Departments (EDs) is increasing. A substantial number of patients is self-referred, but does not need emergency care. In order to have more influence on unnecessary self-referral, it is essential to know why patients visit the ED without referral. The goal of this systematic review therefore is to explore what motivates self-referred patients in those countries to visit the ED. METHODS Recommendations from the PRISMA were used to search and analyze the literature. The following databases; PUBMED, MEDLINE, EMBASE, CINAHL and Cochrane Library, were systematically searched from inception up to the first of February 2015. The reference lists of the included articles were screened for additional relevant articles. All studies that reported on the motives of self-referred patients to visit an ED were selected. The reasons for self-referral were categorized into seven main themes: health concerns, expected investigations; convenience of the ED; lesser accessibility of primary care; no confidence in general practitioner/primary care; advice from others and financial considerations. A random-effects meta-analysis was performed. RESULTS Thirty publications were identified from the literature studied. The most reported themes for self-referral were 'health concerns' and 'expected investigations': 36% (95% Confidence Interval 23-50%) and 35% (95% CI 20-51%) respectively. Financial considerations most often played a role in the United States with a reported percentage of 33% versus 4% in other countries (p < 0.001). CONCLUSIONS Worldwide, the most important reasons to self-refer to an ED are health concerns and expected investigations. Financial considerations mainly play a role in the United States.
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Affiliation(s)
- Nicole Kraaijvanger
- Emergency Department, Rijnstate Hospital, Wagnerlaan 55, Arnhem, The Netherlands
| | - Henk van Leeuwen
- Department of Intensive Care / Internal Medicine, Rijnstate Hospital, Wagnerlaan 55, Arnhem, The Netherlands
| | - Douwe Rijpsma
- Emergency Department, Rijnstate Hospital, Wagnerlaan 55, Arnhem, The Netherlands
| | - Michael Edwards
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein-Zuid 10, Nijmegen, The Netherlands
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28
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Van den Heede K, Van de Voorde C. Interventions to reduce emergency department utilisation: A review of reviews. Health Policy 2016; 120:1337-1349. [PMID: 27855964 DOI: 10.1016/j.healthpol.2016.10.002] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/30/2016] [Accepted: 10/04/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To describe policy interventions that have the objective to reduce ED use and to estimate their effectiveness. METHODS Narrative review by searching three electronic databases for scientific literature review papers published between 2010 and October 2015. The quality of the included studies was assessed with AMSTAR, and a narrative synthesis of the retrieved papers was applied. RESULTS Twenty-three included publications described six types of interventions: (1) cost sharing; (2) strengthening primary care; (3) pre-hospital diversion (including telephone triage); (4) coordination; (5) education and self-management support; (6) barriers to access emergency departments. The high number of interventions, the divergent methods used to measure outcomes and the different populations complicate their evaluation. Although approximately two-thirds of the primary studies showed reductions in ED use for most interventions the evidence showed contradictory results. CONCLUSION Despite numerous publications, evidence about the effectiveness of interventions that aim to reduce ED use remains insufficient. Studies on more homogeneous patient groups with a clearly described intervention and control group are needed to determine for which specific target group what type of intervention is most successful and how the intervention should be designed. The effective use of ED services in general is a complex and multi-factorial problem that requires integrated interventions that will have to be adapted to the specific context of a country with a feedback system to monitor its (un-)intended consequences. Yet, the co-location of GP posts and emergency departments seems together with the introduction of telephone triage systems the preferred interventions to reduce inappropriate ED visits while case-management might reduce the number of ED attendances by frequent ED users.
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Affiliation(s)
- Koen Van den Heede
- Belgian Healthcare Knowledge Centre (KCE), Kruidtuinlaan 55, 1000 Brussels, Belgium.
| | - Carine Van de Voorde
- Belgian Healthcare Knowledge Centre (KCE), Kruidtuinlaan 55, 1000 Brussels, Belgium.
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29
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Thijssen WAMH, Kraaijvanger N, Barten DG, Boerma MLM, Giesen P, Wensing M. Impact of a well-developed primary care system on the length of stay in emergency departments in the Netherlands: a multicenter study. BMC Health Serv Res 2016; 16:149. [PMID: 27117479 PMCID: PMC4845371 DOI: 10.1186/s12913-016-1400-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 04/18/2016] [Indexed: 11/10/2022] Open
Abstract
Background The Netherlands has a well-developed primary care system, which increasingly collaborates with hospital emergency departments (EDs). In this setting, insight into crowding in EDs is limited. This study explored links between patients’ ED Length of Stay (LOS) and their care pathways. Methods Observational multicenter study of 7000 ED patient records from 1 February 2013. Seven EDs spread over the Netherlands, representing overall Dutch EDs, were included. This included three EDs with and four EDs without an integrated primary-care-physician (PCP) cooperative, forming one Emergency Care Access Point (ECAP). The main outcome was LOS of patients comparing different care pathways (origin and destination of ED attenders). Results The median LOS of ED attenders was 130.0 min (IQR 79.0–140.0), which increased with patients’ age. Random coefficient regression analysis showed that LOS for patients referred by medical professionals was 32.9 min longer compared to self-referred patients (95 % CI 27.7–38.2 min). LOS for patients admitted to hospital was 41.2 min longer compared to patients followed-up at the outpatient clinic (95 % CI 35.3–46.6 min), 49.9 min longer compared to patients followed-up at the PCP (95 % CI 41.5–58.3 min) and 44.6 min longer compared to patients who did not receive follow-up (95 % CI 38.3–51.0 min). There was no difference in LOS between hospitals with or without an ECAP. Conclusions With 130 min, the median LOS in Dutch EDs is relatively short, comparing to other Western countries, which ranges from 176 to 480 min. Although integration of EDs with out-of-hours primary care was not related to LOS, the strong primary care system probably contributed to the overall short LOS of ED patients in the Netherlands.
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Affiliation(s)
- Wendy A M H Thijssen
- Emergency Department, Catharina Hospital, Michelangelolaan 2, Postbus 1350, 5602ZA, Eindhoven, The Netherlands. .,Radboud University Medical Centre, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands.
| | | | - Dennis G Barten
- Emergency Department, VieCuri Medical Center, Venlo, The Netherlands
| | | | - Paul Giesen
- Radboud University Medical Centre, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud University Medical Centre, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands
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30
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Ramlakhan S, Mason S, O'Keeffe C, Ramtahal A, Ablard S. Primary care services located with EDs: a review of effectiveness. Emerg Med J 2016; 33:495-503. [PMID: 27068868 DOI: 10.1136/emermed-2015-204900] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 12/26/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Primary care focused unscheduled care centres (UCC) co-located with major EDs have been proposed as a solution to the rise in ED attendances. They aim to reduce the burden of primary care patients attending the ED, hence reducing crowding, waits and cost.This review analysed available literature in the context of the impact of general practitioner (GP) delivered, hospital-based (adjacent or within the ED) unscheduled care services on process outcomes, cost-effectiveness and patient satisfaction. METHODS A narrative literature review of studies published between 1980 and 2015 was undertaken. All study types were reviewed and included if they reported a service model using hospital-based primary care clinicians with a control consisting of standard ED clinician-delivered care. RESULTS The electronic searches yielded 7544 citations, with 20 records used in the review. These were grouped into three main themes: process outcomes, cost-effectiveness and satisfaction. A paradoxical increase in attendances has been described, which is likely to be attributable to provider-induced demand, and the evidence for improved throughput is poor. Marginal savings may be realised per patient, but this is likely to be overshadowed by the overall cost of introducing a new service. CONCLUSIONS There is little evidence to support the implementation of co-located UCC models. A robust evaluation of proposed models is needed to inform future policy.
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Affiliation(s)
- Shammi Ramlakhan
- Sheffield Children's Hospital, Sheffield, UK School of Health & Related Research, University of Sheffield, Sheffield, UK Sheffield Teaching Hospitals, Sheffield, UK
| | - Suzanne Mason
- School of Health & Related Research, University of Sheffield, Sheffield, UK Sheffield Teaching Hospitals, Sheffield, UK
| | - Colin O'Keeffe
- School of Health & Related Research, University of Sheffield, Sheffield, UK
| | | | - Suzanne Ablard
- School of Health & Related Research, University of Sheffield, Sheffield, UK
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31
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van der Biezen M, Schoonhoven L, Wijers N, van der Burgt R, Wensing M, Laurant M. Substitution of general practitioners by nurse practitioners in out-of-hours primary care: a quasi-experimental study. J Adv Nurs 2016; 72:1813-24. [PMID: 26969826 DOI: 10.1111/jan.12954] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2016] [Indexed: 11/30/2022]
Abstract
AIM To provide insight into the impact of substituting general practitioners with nurse practitioners in out-of-hours services on: (1) the number of patients; and (2) general practitioners' caseload (patient characteristics, urgency levels, types of complaints). BACKGROUND General practitioners' workload during out-of-hours care is high, and the number of hours they work out-of-hours has increased, which raises concerns about maintaining quality of care. One response to these challenges is shifting care to nurse practitioners. DESIGN Quasi-experimental study comparing differences between and within out-of-hours teams: experimental, one nurse practitioner and four general practitioners; control, five general practitioners. METHODS Data of 12,092 patients from one general practitioners cooperative were extracted from medical records between April 2011 and July 2012. RESULTS The number of patients was similar in the two study arms. In the experimental arm, the nurse practitioner saw on average 16·3% of the patients and each general practitioner on average 20·9% of the patients. General practitioners treated more older patients; higher urgency levels; and digestive, cardiovascular and neurological complaints. Nurse practitioners treated more patients with skin and respiratory complaints. Substitution did not lead to a meaningful increase of general practitioners' caseload. CONCLUSION The results show that nurse practitioners can make a valuable contribution to patient care during out-of-hours. The patients managed and care provided by them is roughly the same as general practitioners. In areas with a shortage of general practitioners, administrators could consider employing nurses who are competent to independently treat patients with a broad range of complaints to offer timely care to patients with acute problems.
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Affiliation(s)
- Mieke van der Biezen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | | | | | - Regi van der Burgt
- Foundation for Development of Quality Care in General Practice, Eindhoven, The Netherlands
| | - Michel Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Miranda Laurant
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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van Veelen MJ, van den Brand CL, Reijnen R, van der Linden MC. Effects of a general practitioner cooperative co-located with an emergency department on patient throughput. World J Emerg Med 2016; 7:270-273. [PMID: 27942343 DOI: 10.5847/wjem.j.1920-8642.2016.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In 2013 a General Practitioner Cooperative (GPC) was introduced at the Emergency Department (ED) of our hospital. One of the aims of this co-located GPC was to improve throughput of the remaining patients at the ED. To determine the change in patient flow, we assessed the number of self-referrals, redirection of self-referrals to the GPC and back to the ED, as well as ward and ICU admission rates and length of stay of the remaining ED population. METHODS We conducted a four months' pre-post comparison before and after the implementation of a co-located GPC with an urban ED in the Netherlands. RESULTS More than half of our ED patients were self-referrals. At triage, 54.5% of these self-referrals were redirected to the GPC. After assessment at the GPC, 8.5% of them were referred back to the ED. The number of patients treated at the ED declined with 20.3% after the introduction of the GPC. In the remaining ED population, there was a significant increase of highly urgent patients (P<0.001), regular admissions (P<0.001), and ICU admissions (P<0.001). Despite the decline of the number of patients at the ED, the total length of stay of patients treated at the ED increased from 14 682 hours in the two months' control period to 14 962 hours in the two months' intervention period, a total increase of 270 hours in two months (P<0.001). CONCLUSION Introduction of a GPC led to efficient redirection of self-referrals but failed to improve throughput of the remaining patients at the ED.
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Affiliation(s)
- Michiel J van Veelen
- Department of Emergency Medicine, University of Botswana, School of Medicine, Gaborone, Botswana
| | | | - Resi Reijnen
- Department of Emergency Medicine, Medical Center Haaglanden, The Hague, The Netherlands
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Turner J, Coster J, Chambers D, Cantrell A, Phung VH, Knowles E, Bradbury D, Goyder E. What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03430] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.ObjectiveThe purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.Data sourcesMEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.MethodsWe have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.ResultsThe review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.LimitationsAlthough there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.ConclusionsThe evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.FundingThe National Institute for Health Research Health Services and Delivery Research Programme.
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Affiliation(s)
- Janette Turner
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Joanne Coster
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Viet-Hai Phung
- College of Social Science, University of Lincoln, Lincoln, UK
| | - Emma Knowles
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Bradbury
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Zwaanswijk M, Nielen MMJ, Hek K, Verheij RA. Factors associated with variation in urgency of primary out-of-hours contacts in the Netherlands: a cross-sectional study. BMJ Open 2015; 5:e008421. [PMID: 26474938 PMCID: PMC4611245 DOI: 10.1136/bmjopen-2015-008421] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Dutch primary out-of-hours care is provided by general practice cooperatives (GPCs). Although most GPCs use the same standardised triage system, differences between GPCs exist in the urgency assigned to patients' health problems. This cross-sectional study aims to provide insight into factors associated with the variation in assigned urgency between GPCs. DESIGN AND METHODS Data were derived from routine electronic health records of 895 253 patients who attended 17 GPCs in 2012. Patients' gender, age, travel distance to the GPC, and the use of a computer-based decision support system for triage were investigated as possibly affecting assigned urgency. Multilevel linear regression analyses were executed for the 3 most frequently presented health problems (cystitis/other urinary infection, laceration/cut and fever). RESULTS Variation in urgency levels between GPCs was significant for the selected health problems (p=0.00). Assigned urgency was mainly related to patient gender and age. It was not associated with the use of a computer-based decision support system, or with travel distance to the GPC. Most variation in urgency (93.4-96.7%) could be ascribed to variation in patient characteristics. CONCLUSIONS There is significant variation in urgency levels between GPCs, even for the same health problem. This variation is mainly associated with differences in characteristics of individuals contacting the GPCs, rather than with variables such as patients' travel distance or the use of a computer-based decision support system. Since patient characteristics are likely to affect patients' clinical need, our results are an indication of the adequate functioning of the triage system.
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Affiliation(s)
- Marieke Zwaanswijk
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Markus M J Nielen
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Karin Hek
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Robert A Verheij
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
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Cowling TE, Ramzan F, Ladbrooke T, Millington H, Majeed A, Gnani S. Referral outcomes of attendances at general practitioner led urgent care centres in London, England: retrospective analysis of hospital administrative data. Emerg Med J 2015; 33:200-7. [PMID: 26396232 DOI: 10.1136/emermed-2014-204603] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 08/26/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To identify patient and attendance characteristics that are associated with onwards referral to co-located emergency departments (EDs) or other hospital specialty departments from general practitioner (GP) led urgent care centres (UCCs) in northwest London, England. METHODS We conducted a retrospective analysis of administrative data recorded in the UCCs at Charing Cross and Hammersmith Hospitals, in northwest London, from October 2009 to December 2012. Attendances made by adults resident in England were included. Logistic regression was used to model the associations between the explanatory variables-age; sex; ethnicity; socioeconomic status; area of residence; distance to UCC; GP registration; time, day, quarter, year; and UCC of attendance-and the outcome of onwards referral to the co-located EDs or other hospital specialty departments. RESULTS Of 243 042 included attendances, 74.1% were managed solely within the UCCs without same day referral to the EDs (16.8%) or other hospital specialty departments (5.7%), or deferred referral to a fracture, hand management or soft tissue injury management clinic (3.3%). The adjusted odds of onwards referral was estimated to increase by 19% (OR 1.19, 95% CI 1.18 to 1.19) for a 10 year increase in a patient's age. Men, patients registered with a GP and residents of less socioeconomically deprived areas were also more likely to be referred onwards from the UCCs. CONCLUSIONS The majority of patients, across each category of all explanatory variables, were managed solely within the UCCs, although a large absolute number of patients were referred onwards each year. Several characteristics of patients and their attendances were associated with the outcome variable.
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Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Farzan Ramzan
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Tim Ladbrooke
- London Central and West Unscheduled Care Collaborative, London, UK
| | - Hugh Millington
- Emergency Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Shamini Gnani
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Thijssen WAMH, van Miero E, Willekens M, Rebel J, Sandel MH, Giesen P, Wensing M. Complaints and Diagnoses of Emergency Department Patients in the Netherlands: A Comparative Study of Integrated Primary and Emergency Care. PLoS One 2015; 10:e0129739. [PMID: 26131564 PMCID: PMC4488864 DOI: 10.1371/journal.pone.0129739] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 05/12/2015] [Indexed: 11/18/2022] Open
Abstract
Objective In the Netherlands, an increasing number of emergency departments (EDs) and general practitioner cooperatives collaborate by creating one Emergency-Care-Access-Point (ECAP). This has resulted in fewer patients at ECAP EDs. The objective of this study was to explore differences in patient characteristics, presented complaints and ED discharge diagnoses between EDs with an ECAP and EDs without an ECAP. Methods A retrospective observational study was performed with 1800 consecutive patient records sampled from six EDs spread over the Netherlands in 2013. We extracted data on time and date of presentation, sex, age, presenting complaint, discharge diagnosis, origin and follow up. Results At ECAP EDs, the mean age was 47.8 years (95%CI 46.1-49.4) compared to 41.3 (95%CI 39.7-42.9). Compared to non-ECAP EDs, more patients were referred by medical professionals (74.7% versus 46.8%), more patients received hospital admission (45.2% versus 29.0%) and fewer patients received GP follow-up (4.1% versus 16.9%). There was no significant difference in presenting complaints between ECAP and non-ECAP EDs. Most prevalent complaints were trauma (25.7% versus 29.7%), abdominal pain (12.1% versus 10.9%) and general symptoms (7.8% versus 4.8%). The most prevalent ED diagnoses significantly differed with fractures and dislocations (10.8%), sprains and strains (10.4%) and respiratory infections (6.8%) at ECAP EDs versus fractures and dislocations (10.7%), wounds (9.3%) and sprains and strains (8.9%) at non-ECAP EDs. Conclusion Compared to non-ECAP EDs, patients at ECAP EDs were older, medical professionals referred more patients and more patients received a hospital admission. We found some small differences in discharge diagnoses between ECAP EDs compared to non-ECAP EDs, but no difference in presented complaints.
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Affiliation(s)
- Wendy A. M. H. Thijssen
- Emergency Department, Catharina Hospital, Eindhoven, the Netherlands
- IQ Scientific Institute for Quality of Health Care, Radboud University, Nijmegen Medical Centre, Nijmegen, the Netherlands
- * E-mail:
| | - Elske van Miero
- Emergency Department, Catharina Hospital, Eindhoven, the Netherlands
| | - Maartje Willekens
- Emergency Department, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Jasper Rebel
- Emergency Department, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Maro H. Sandel
- Emergency Department, Haga Hospital, The Hague, the Netherlands
| | - Paul Giesen
- IQ Scientific Institute for Quality of Health Care, Radboud University, Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Michel Wensing
- IQ Scientific Institute for Quality of Health Care, Radboud University, Nijmegen Medical Centre, Nijmegen, the Netherlands
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Bergmark RW, Ishman SL, Scangas GA, Cunningham MJ, Sedaghat AR. Socioeconomic determinants of overnight and weekend emergency department use for acute rhinosinusitis. Laryngoscope 2015; 125:2441-6. [DOI: 10.1002/lary.25390] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/16/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Regan W. Bergmark
- Department of Otolaryngology-Head and Neck Surgery ; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
- Department of Otology and Laryngology ; Harvard Medical School; Boston Massachusetts
| | - Stacey L. Ishman
- Division of Otolaryngology-Head and Neck Surgery (s.l.i.)
- Division of Pulmonary Medicine ; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
- Department of Otolaryngology-Head & Neck Surgery ; University of Cincinnati; Cincinnati Ohio
| | - George A. Scangas
- Department of Otolaryngology-Head and Neck Surgery ; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
- Department of Otology and Laryngology ; Harvard Medical School; Boston Massachusetts
| | - Michael J. Cunningham
- Department of Otology and Laryngology ; Harvard Medical School; Boston Massachusetts
- Department of Otolaryngology and Communications Enhancement ; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Ahmad R. Sedaghat
- Department of Otolaryngology-Head and Neck Surgery ; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
- Department of Otology and Laryngology ; Harvard Medical School; Boston Massachusetts
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Jansen T, Zwaanswijk M, Hek K, de Bakker D. To what extent does sociodemographic composition of the neighbourhood explain regional differences in demand of primary out-of-hours care: a multilevel study. BMC FAMILY PRACTICE 2015; 16:54. [PMID: 25943593 PMCID: PMC4424822 DOI: 10.1186/s12875-015-0275-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 04/27/2015] [Indexed: 11/13/2022]
Abstract
BACKGROUND In the Netherlands, primary out-of-hours (OOH) care is provided by large scale General Practitioner (GP) cooperatives. GP cooperatives can be contacted by patients living in the area surrounding the GP cooperative (catchment area) at hours when the patient's own general practice is closed. The frequency of primary OOH care use substantially differs between GP cooperative catchment areas. To enable a better match between supply and demand of OOH services, understanding of the factors associated with primary OOH care use is essential. The present study evaluated the contribution of sociodemographic composition of the neighbourhood in explaining differences in primary OOH care use between GP cooperative catchment areas. METHODS Data about patients' contacts with primary OOH services (n = 1,668,047) were derived from routine electronic health records of 21 GP cooperatives participating in the NIVEL Primary Care Database in 2012. The study sample is representative for the Dutch population (for age and gender). Data were matched with sociodemographic characteristics (e.g. gender, age, low-income status, degree of urbanisation) on postcode level. Multilevel linear regression models included postcode level (first level), nested within GP cooperative catchment areas (second level). We investigated whether contacts in primary OOH care were associated with neighbourhood sociodemographic characteristics. RESULTS The demand of primary OOH care was significantly higher in neighbourhoods with more women, low-income households, non-Western immigrants, neighbourhoods with a higher degree of urbanisation, and low neighbourhood socioeconomic status. Conversely, lower demand was associated with neighbourhoods with more 5 to 24 year old inhabitants. Sociodemographic neighbourhood characteristics explained a large part of the variation between GP cooperatives (R-squared ranging from 8% to 52%). Nevertheless, the multilevel models also showed that a considerable amount of variation in demand between GP cooperatives remained unexplained by sociodemographic characteristics, particularly regarding high-urgency contacts. CONCLUSIONS Although part of the variation between GP cooperatives could not be attributed to neighbourhood characteristics, the sociodemographic composition of the neighbourhood is a fair predictor of the demand of primary OOH care. Accordingly, this study provides a useful starting point for an improved planning of the supply of primary OOH care.
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Affiliation(s)
- Tessa Jansen
- NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN, Utrecht, The Netherlands.
| | - Marieke Zwaanswijk
- NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN, Utrecht, The Netherlands.
| | - Karin Hek
- NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN, Utrecht, The Netherlands.
| | - Dinny de Bakker
- NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN, Utrecht, The Netherlands.
- Department of Social and behavioural science, Scientific Centre for Transformation in Care and Welfare (TRANZO), Tilburg University, PO Box 90153, 5000 LE, Tilburg, The Netherlands.
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Wiler JL, Welch S, Pines J, Schuur J, Jouriles N, Stone-Griffith S. Emergency department performance measures updates: proceedings of the 2014 emergency department benchmarking alliance consensus summit. Acad Emerg Med 2015; 22:542-53. [PMID: 25899754 DOI: 10.1111/acem.12654] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/03/2014] [Accepted: 11/12/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective was to review and update key definitions and metrics for emergency department (ED) performance and operations. METHODS Forty-five emergency medicine leaders convened for the Third Performance Measures and Benchmarking Summit held in Las Vegas, February 21-22, 2014. Prior to arrival, attendees were assigned to workgroups to review, revise, and update the definitions and vocabulary being used to communicate about ED performance and operations. They were provided with the prior definitions of those consensus summits that were published in 2006 and 2010. Other published definitions from key stakeholders in emergency medicine and health care were also reviewed and circulated. At the summit, key terminology and metrics were discussed and debated. Workgroups communicated online, via teleconference, and finally in a face-to-face meeting to reach consensus regarding their recommendations. Recommendations were then posted and open to a 30-day comment period. Participants then reanalyzed the recommendations, and modifications were made based on consensus. RESULTS A comprehensive dictionary of ED terminology related to ED performance and operation was developed. This article includes definitions of operating characteristics and internal and external factors relevant to the stratification and categorization of EDs. Time stamps, time intervals, and measures of utilization were defined. Definitions of processes and staffing measures are also presented. Definitions were harmonized with performance measures put forth by the Centers for Medicare and Medicaid Services (CMS) for consistency. CONCLUSIONS Standardized definitions are necessary to improve the comparability of EDs nationally for operations research and practice. More importantly, clear precise definitions describing ED operations are needed for incentive-based pay-for-performance models like those developed by CMS. This document provides a common language for front-line practitioners, managers, health policymakers, and researchers.
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Affiliation(s)
- Jennifer L. Wiler
- Department of Emergency Medicine; University of Colorado School of Medicine; Aurora CO
| | - Shari Welch
- Intermountain Institute for Healthcare Delivery Research; Salt Lake City UT
- Emergency Department Benchmarking Alliance; Newark DE
| | - Jesse Pines
- Department of Emergency Medicine; George Washington University; Washington DC
| | - Jeremiah Schuur
- Department of Emergency Medicine; Brigham and Women's Hospital and Harvard University; Boston MA
| | - Nick Jouriles
- Department of Emergency Medicine; Northeast Ohio Medical University; Akron OH
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