Introduction

60% of patients attending the emergency department (ED) in the UK are non-urgent.[₁] Of those, 20-30% can be treated in the primary care setting.[₂,₃] In fact, 3.5% of patients who can be considered for discharge from triage have already consulted primary care (PC).[₃]

Patients referred by a general practitioner (GP) to the ED are expected to require ED facilities (diagnostic or therapeutic) or expertise. However, the individual skills of the GP, patient demand, and fear of litigation are major determinants of referral behavior.[₄] To monitor these referral patterns, studies need to be based on analysis of clinical cases rather than on rates of referral. [₄]

This study aimed to review episodes of GP referrals to ED by analysing these referrals and establishing their suitability. This may provide baseline information for streamlining these referrals and introducing appropriate guidelines that may decrease the burden on ED, improve performance and avoid unnecessary use of resources

Materials & Methods

This is a prospective study, conducted at the ED of Hinchingbrooke hospital, United Kingdom, attended by 39,955 patients during the study year. Over a period of 3 months (May-August 2004), 240 consecutive cases referred from GPs to the ED were identified. The patients' notes were reviewed at the end of the collection period. The ED input (i.e. procedures investigations or treatment), diagnosis and outcome (i.e. discharge, further referral to admitting specialties) were recorded for each case. The cases were eventually categorized as follows:

ED case: Patients whose management required procedures or investigations that can not be offered at the usual primary care settings. These included intravenous medications or analgesics that require monitoring, blood or radiological investigations, wound suturing, fracture manipulation or any other procedure or investigation that is not performed in the usual primary care settings.

Primary Care (PC) case: Patients treated and discharged from ED without requiring any investigation or procedure beyond those of primary care capabilities.

Specialty case: Patients who required further referral to the relevant specialty on call for further assessment or management.

X-ray case: Patients who were referred to the ED for the purpose of radiographic assessment, either by referring the patient to the ED before the x-ray was performed, or by sending the patient directly to the radiology department, and eventually to be assessed at the ED regardless of the x-ray findings.

The above classifications were reviewed and approved by the three authors, and an independent GP trainee working in the same ED.

Results

Only 13.8% of the referrals were deemed requiring direct ED input (ED case) (Table 1). Most of the PC cases were minor trauma cases (80%) that did not require further radiological assessment (figure 1). Of these, 11 were minor head injuries that were discharged after providing head injury instructions along with NICE head injury guidelines.

70.2% (73 patients) of the x-ray referrals showed no fractures and did not require urgent management. The majority of these referrals were for upper or lower limb x-rays (Table 2).

Figure 1

Table 1: Analysis of GP referrals to ED

Figure 2

Table 2: Regional distribution of the X-ray Referrals.

The referrals were further categorised into trauma and non trauma cases as in figure 1.

Figure 3

Figure 1: The bar chart shows the studied 240 referrals categorized into Emergency Department (ED), Primary Care (PC), Specialty, and X-ray cases. Each category is further subdivided into Trauma (grey) and Non Trauma cases.

Discussion

The results showed that 73.3 % of the studied referrals could have been managed without requiring direct ED input (PC cases, 65; Speciality cases, 38; and negative X-ray cases, 73). These referrals included patients who could have been managed in a primary care setting, patients for whom direct referral to an admitting specialty would have been preferable, and those who could have been referred directly to the radiology department for x-ray assessment without using the ED as a conduit.

27% of the referrals could have been managed equally well in a primary care setting (PC cases). Integration of primary care services into the ED or employing GPs managing minor trauma may present a solution for these referrals.[₅,₆] In fact, GPs working in ED manage non-emergency patients safely and use fewer resources than do usual ED staff.[₇,₈,₉]

It is estimated that approximately one-half of patients attending ED will require an x-ray [₁₀]. Similarly, 43.3% of the studied referrals were for radiographic assessment. Most of these referrals (70.2%) did not demonstrate positive findings or require urgent ED input. Appropriately trained and supervised radiographers can successfully undertake diagnostic reporting of skeletal examinations on ED patients.[₁₁,₁₂] In addition, to avoid litigation of a missed fracture, it has become standard practice for all ED radiographs to be formally reported by a radiologist.[₁₃,₁₄] Therefore, direct referral of patients who do not require immediate ED input to the radiology department, can minimise unnecessary x-ray referrals, as patients with no abnormal x-ray findings can be directed back to the referring GP without direct ED input.

Conclusion

This study showed that a great proportion of GP referrals to ED can be streamlined into more efficient pathways which can potentially decrease the burden on the ED, improve performance and avoid unnecessary use of resources. These referral behaviors are affected by the individual skills of the general practitioner, patient demand, and fear of litigation. However, analyses of the referral patterns and introduction of appropriate guidelines may help streamline these referrals. Although the same patterns of referrals can be found in most emergency departments, variation in the available resources and local practice may dictate specific guidelines for individual emergency departments.

Consequently, the ED at Hinchingbrooke hospital is undergoing major changes, introducing the new Emergency Care Centre which includes the emergency department, the out of hours GP centre, and some of the primary care on call services. This is likely to provide better integrated services and streamline patients' management pathways.

Correspondence to

Feras Ya'ish Flat 14, Pinnacle House, 632 Evesham Road, Redditch B97 5LH United Kingdom Tel: 00 44 77 88 54 33 24 E-mail: firasyaish2@hotmail.com