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• The effectiveness of primary care services located within EDs - optimising streaming
  Martin M McGrath
  Published on: 20 July 2016
• Designing urgent primary care centres located at hospital sites: the devil is in the details
  Koen Van den Heede
  Published on: 20 June 2016
• Primary care services located with EDs: Effectiveness depends on matching patients to the right clinician
  Tim Daniel
  Published on: 25 April 2016

• Published on: 20 July 2016

  The effectiveness of primary care services located within EDs - optimising streaming

  • Martin M McGrath, Doctor
  • Other Contributors:
    • Claire Blackmore, Amardeep Heer, Stuart Maitland-Knibb, Sam Stemp, Ben Wilczynski.

  The comprehensive review by Ramlakhan et al of the effectiveness of primary care services located within EDs draws mixed conclusions. Whilst initial efficiency savings were identified (both in terms of GP resource utilisation and overall cost) and subsequent hospital admission and referrals appeared reduced, other outcomes proved disappointing or at best equivocal including length of stay, waiting time and patient satisfa...

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  The comprehensive review by Ramlakhan et al of the effectiveness of primary care services located within EDs draws mixed conclusions. Whilst initial efficiency savings were identified (both in terms of GP resource utilisation and overall cost) and subsequent hospital admission and referrals appeared reduced, other outcomes proved disappointing or at best equivocal including length of stay, waiting time and patient satisfaction.

  Given the ongoing critical performance challenges faced by hospitals, that not only derive from increasing volumes of attendance (whether through provider-induced demand or otherwise) but also the effect consequently imposed by inefficiencies and the internal degradation of pathways, Emergency Departments need to do something radical. The crucial importance of optimising hospital productivity legitimises the use of novel streaming services that aim both to minimise the effect on the hospital of low acuity patients and, specifically, to de-bulk ED Majors attendance. If a streaming service is to be used, then the same article's review by Abdulwahid et al identifies the positive impact of senior doctor assessment at triage. In contrast to the mainly senior ED clinicians that were reviewed in this paper, our own belief is that senior GPs have a better chance of deflecting or re-directing potential admissions, not least because of clinician awareness of community-based options for care.

  The introduction of a streaming service to the front door of Leicester Royal Infirmary (Europe's busiest ED) has aimed to achieve success using immediate clinical assessment by a senior GP on arrival followed by rapid assessment using 3 other streaming GPs. In a 6 month period this small team managed to treat or redirect 19% of all day time walk in patients that presented (equating to 16,094 patients per year not entering hospital) while only admitting 5% of patients to ED Majors. This scale of success in streaming can result in significant performance advantage for the hospital, both effectively redirecting patients that could be cared for elsewhere and optimising use of internal pathways and thereby improving efficiencies.

  References:

  Ramlakhan S, Mason S, O'Keefe C, et al. Emerg Med J 2016;33:495-503.

  Abdulwahid MA, Booth A, Kuczawski M, et al. Emerg Med J 2016;33:504- 513.

  Conflict of Interest:

  Dr Martin McGrath and Dr Stuart Maitland-Knibb are directors of Lakeside+ Ltd, the company providing the streaming service described at LRI.

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  Conflict of Interest:
  None declared.

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• Published on: 20 June 2016

  Designing urgent primary care centres located at hospital sites: the devil is in the details

  • Koen Van den Heede, Senior expert Health Services Research
  • Other Contributors:
    • Carine Van de Voorde

  We have read with great interest the review of Ramlakhan et al. (2016)1 on the effectiveness of co-locating emergency departments (ED) and primary care centres and the findings of the authors that the evidence is inconclusive. Yet, we are confident that there are more hints and clues in the available evidence for policy guidance than was done in the paper by Ramlakhan et al. (2016). We will illustrate this with a recent po...

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  We have read with great interest the review of Ramlakhan et al. (2016)1 on the effectiveness of co-locating emergency departments (ED) and primary care centres and the findings of the authors that the evidence is inconclusive. Yet, we are confident that there are more hints and clues in the available evidence for policy guidance than was done in the paper by Ramlakhan et al. (2016). We will illustrate this with a recent policy analysis carried out in Belgium.2 As Burke (2016)3 states in his editorial it is key to determine the goals of your policy intervention (e.g. improved access; improved flow; reduced costs; improved patient satisfaction) and to monitor the implementation of new models. That is exactly what we have proposed by recommending a 'proof of concept evaluation' for 24/7 GP posts that are co-located with the ED (with one entrance and a joint triage area) in order to substitute ED care by primary care. Indeed, substituting more expensive ED resources by primary care resources seems a legitimate policy goal. Belgium has a very high self-referral rate (71%) and a large share of ED contacts are ambulatory contacts (77%). Furthermore, estimates of inappropriate ED contacts (40-56%) are higher than the internationally reported figures of 20-40%.4 As in other countries there is an ever increasing use of EDs which is in Belgium mainly observed for ambulatory and self-referred ED contacts. In addition, previous policy measures such as large investments in out-of-hours GP posts were unsuccessful in stopping this increasing trend. Most of these out-of-hours GP posts were not located at hospital sites. In the rare occasions where a GP post was co-located with an ED they had separate entrances and triage zones not resulting in substitution.5 Why did our policy recommendation to install GP posts on ED-sites deviate from the inconclusive findings in the Ramlakhan et al. (2016) review? Our review of the literature showed that 'design elements' are essential for successful substitution of ED care by primary care. We believe that these design elements are insufficiently analysed in the Ramlakhan et al. (2016) study. In their review several divergent models of co-location were assessed simultaneously (e.g. nurse-led walk-in clinics instead of GP-lead urgent care centres; models with separate entrances and triage areas for the primary care centre and the ED instead of one central entrance and joint triage area; or even models without a triage function). When analysing these studies more in-depth, it is clear that these design elements are making the difference in substituting ED by primary care. Indeed, 'the devil is in the details'. A difference in prescriptions of medical imaging and laboratory tests can, for instance, be observed when the initial triage process was carried out by trained nurses while this was not the case when triage was done by a receptionist. Moreover, three recent studies which were not included (van Gils-van Rooij (2015)6 for the Netherlands; Cowling et al. (2016)7 for England; Eichler et al. (2014)8 for Switzerland) showed that: a co-location of GP posts with one entrance and joint triage area is effective in reducing the number of self-referred ED contacts; the largest portion of contacts triaged towards the GP does only require care from the GP; and that GPs prescribe less medical imaging and lab tests compared to emergency physicians. We also acknowledge that the literature is not straightforward. Indeed, several reviews9 10 illustrated that an expansion of the available services might unmask latent demand and will increase the overall burden on the emergency care system even more. However, it cannot be concluded from the available studies that this increase in activity is caused by overuse (e.g. shift from regular GP contacts towards urgent care centres) nor by underuse. To account for these and other potential unintended effects we recommend a 'proof of concept' evaluation where these (un- )intended are carefully monitored.

  Reference List

  1. Ramlakhan S, Mason S, O'Keeffe C, et al. Primary care services located with EDs: a review of effectiveness. Emerg Med J 2016.

  2. Van den Heede K, Dubois C, Devriese S, et al. Organisation and payment of emergency care services in Belgium: current situation and options for reform. Health Services Research (HSR). Brussels: Belgian Health Care Knowledge Centre (KCE), 2016.

  3. Burke D. Primary care services located with EDs: a review of effectiveness. Emerg Med J 2016.

  4. Carret ML, Fassa AC, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009;25(1):7-28.

  5. Philips H, Remmen R, Van Royen P, et al. What's the effect of the implementation of general practitioner cooperatives on caseload? Prospective intervention study on primary and secondary care. BMC health services research 2010;10:222.

  6. van Gils-van Rooij ES, Yzermans CJ, Broekman SM, et al. Out-of- Hours Care Collaboration between General Practitioners and Hospital Emergency Departments in the Netherlands. J Am Board Fam Med 2015;28(6):807-15.

  7. Cowling TE, Ramzan F, Ladbrooke T, et al. Referral outcomes of attendances at general practitioner led urgent care centres in London, England: retrospective analysis of hospital administrative data. Emerg Med J 2016;33(3):200-7.

  8. Eichler K, Hess S, Chmiel C, et al. Sustained health-economic effects after reorganisation of a Swiss hospital emergency centre: a cost comparison study. Emerg Med J 2014;31(10):818-23.

  9. Ismail SA, Gibbons DC, Gnani S. Reducing inappropriate accident and emergency department attendances: A systematic review of primary care service interventions. British Journal of General Practice 2013;63(617):e813-e20.

  10. Morgan SR, Chang AM, Alqatari M, et al. Non-emergency department interventions to reduce ED utilization: a systematic review. Academic Emergency Medicine 2013;20(10):969-85.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 25 April 2016

  Primary care services located with EDs: Effectiveness depends on matching patients to the right clinician

  • Tim Daniel, Consultant in Public Health Medicine/GP
  • Other Contributors:
    • Ursula Montgomery, Catherine Free

  We read with interest the paper by Ramlakhan et al (10.1136/emermed- 2015-204900) on the effectiveness of primary care services located in EDs. We have just completed a test cycle week of a GP led model for managing lower acuity patients who present to the Clinical Decisions Unit (CDU) at the Glenfield Hospital, Leicester; however, we reached different conclusions. The CDU is a cardiorespiratory unit that receives mixed...

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  We read with interest the paper by Ramlakhan et al (10.1136/emermed- 2015-204900) on the effectiveness of primary care services located in EDs. We have just completed a test cycle week of a GP led model for managing lower acuity patients who present to the Clinical Decisions Unit (CDU) at the Glenfield Hospital, Leicester; however, we reached different conclusions. The CDU is a cardiorespiratory unit that receives mixed acuity urgent patients 24 hours a day from a range of sources (999 ambulance, GP referrals and transfers from both the local ED department and Urgent Care Centre located on the same site two miles away), but not self-referrals. The specialist teams are unable to rapidly manage and discharge low acuity patients because the hospital processes and IT systems were not designed for this purpose, resulting in overcrowding and inefficiency. A GP/specialist nurse 'fast track' area was created to rapidly diagnose (with access to chest x-ray and bloods), and discharge safely, all patients triaged by experienced nurses at the 'front door' as potentially fit for same day discharge using the primary care IT system (SystmOne). 67 patients comprising approximately 30-40% of total attendances were seen and 88% were discharged (mean of 116 minutes compared with up to 6 hours at peak periods of activity). No adverse events or seven day readmissions have been reported. Both patient and staff satisfaction was high. The overall proportion of patients who left the department in less than 6 hours (throughput/flow) increased by around 10% easing pressure on specialists who could then focus on the sicker cohort of patients. GPs handle low acuity problems faster because that fits in with their training and skill set (they appraise rapidly and decide). It is a matter of 'right patient in front of the right clinician'. We are planning a further eight week pilot to consider the cost effectiveness of our model, greater integration with the local urgent care system and the best clinician to triage on arrival.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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