edadmin:ed_nonurgentpatients

"non urgent" patients in the ED

Introduction

Governments are often very keen to explain away ED bed access block and over-crowding as being largely due to excessive numbers of patients attending the ED who should really be attending general practitioners (GPs).
the ACEM fact sheet (pdf) published in 2001 clearly shows that triage 4 and 5 patients attending EDs are in general, DIFFERENT to GP patients on a number of parameters:
- admission rates for triage 4 and 5 patients are 5-20% whilst for patients seeing GPs or locum services it is less than 2%, thereby suggesting a very different acuity.
- the average doctor consultation time is 25-40min for triage 4/5 patients whilst it is only 5-10min for GP patients.
- there is a significant mortality rate amongst triage 4 patients
- many triage 4 or 5 patients require timely pathology, radiology investigations or procedures not available in most GP settings.
- a large proportion of triage 4 and 5 patients are actually referred to the ED by GPs
- ED's with standalone extended hour GP clinics in close proximity (<200m) have similar proportions of triage 4 and 5 patients as EDs which do not have nearby clinics.
- most triage 4 and 5 patients attend during hours when GPs are most available.
true GP-type patients are NOT likely to contribute to ED overcrowding at times of bed access block as:
- they usually do not get to take up a valuable ED cubicle
- a large proportion will fail to wait to be seen and leave at their own risk - in many hospitals in Winter demand times, such did not wait (DNW) rates are commonly 30-35% for this sub-group of patients compared to less than 8% for non-GP type patients.
“fast-track” streaming:
- many hospitals recognise the importance in timely treatment of these “less urgent” patients who are not true GP patients, via a number of initiatives such as:
  - allocation of minor fractures, lacerations, threatened miscarriage, etc to a “fast track” streaming process with dedicated ED staff which often include nurse practitioners.
  - nurse-initiated investigations at triage such as referring patients to XRay or sending pathology tests as per careplans for common presenting problems.
- it is important that such streaming models are appropriately resourced such that they are available when needed, provide for adequate patient examination and privacy, and they do not adversely impact on timely care to the “more time critical” triage 1-3 patients.
- it is important that such streaming models are designed so that it does NOT encourage true GP-type patients to attend the ED
  - ED doctors are not GPs and do not have the same skill set to best manage GP-type problems
  - encouraging true GP type patients will only:
    - encourage inappropriate behaviour patterns (further reinforced by the reduced cost of investigations, consultations and pharmacy as well as the potential for more timely investigation and the potential for one-stop care)
    - do such patients a disservice as they may not get the type of care they really need and prevent them establishing a long term professional relationship and rapport with a GP which is important for continuity of care as well as ensuring preventive medicine principles are encouraged.
  - economics 101 states that whenever there is a valued resource in demand, consumers will access it while its relative cost (in terms of either money, time, inconvenience, etc) is outweighed by its perceived benefits which will inevitably result in increased queues unless resources are thrown at the service or cost for the service is increased.
co-located GP clinics:
- over the past decade multiple attempts have been made by governments to introduce co-located GP clinics - usually staffed by GPs who are paid at significantly higher rates than ED specialist physicians.
- in general, it would appear these have only added to the woes of the ED by changing patient behaviour to attend the centre and when the clinic reaches capacity or doctors are unavailable, these patients then migrate to the ED for care.
- it should be clear from the above that GP-type patients are NOT a big issue in ED overcrowding and thus a GP co-located clinic is unlikely to improve ED overcrowding, although they may allow true GP type patients to be more readily redirected from the ED.