General practitioners and emergency departments (GPED)-efficient models of care: a mixed-methods study protocol (original) (raw)
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General practitioners working in or alongside the emergency department: the GPED mixed-methods study
Health and Social Care Delivery Research
Background Emergency care is facing a steadily rising demand. In response, hospitals have implemented new models of care that locate general practitioners in or alongside the emergency department. Objectives We aimed to explore the effects of general practitioners working in or alongside the emergency department on patient care, the primary care and acute hospital team, and the wider system, as well as to determine the differential effects of different service models. Design This was a mixed-methods study in three work packages. Work package A classified current models of general practitioners working in or alongside the emergency department in England. We interviewed national and local leaders, staff and patients to identify the hypotheses underpinning these services. Work package B used a retrospective analysis of routinely available data. Outcome measures included waiting times, admission rates, reattendances, mortality and the number of patient attendances. We explored potential...
BMJ Open
ObjectivesWorldwide, 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.DesignRapid realist literature review.SettingEmergency departments.Inclusion criteriaArticles describing general practitioners working in or alongside emergency departments.AimTo 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.ResultsNinety-si...
BMJ Open, 2022
Objectives To examine the effect of general practitioners (GPs) working in or alongside the emergency department (GPED) on patient outcomes and experience, and the associated impacts of implementation on the workforce. Design Mixed-methods study: interviews with service leaders and NHS managers; in-depth case studies (n=10) and retrospective observational analysis of routinely collected national data. We used normalisation process theory to map our findings to the theory's four main constructs of coherence, cognitive participation, collective action and reflexive monitoring. Setting and participants Data were collected from 64 EDs in England. Case site data included: non-participant observation of 142 clinical encounters; 467 semistructured interviews with policy-makers, service leaders, clinical staff, patients and carers. Retrospective observational analysis used routinely collected Hospital Episode Statistics alongside information on GPED service hours from 40 hospitals for which complete data were available. Results There was disagreement at individual, stakeholder and organisational levels regarding the purpose and potential impact of GPED (coherence). Participants criticised policy development and implementation, and staff engagement was hindered by tensions between ED and GP staff (cognitive participation). Patient 'streaming' processes, staffing and resource constraints influenced whether GPED became embedded in routine practice. Concerns that GPED may increase ED attendance influenced staff views. Our quantitative analysis showed no detectable impact on attendance (collective action). Stakeholders disagreed whether GPED was successful, due to variations in GPED model, site-specific patient mix and governance arrangements. Following statistical adjustment for multiple testing, we found no impact on: ED reattendances within 7 days, patients discharged within 4 hours of arrival, patients leaving the ED without being seen; inpatient admissions; non-urgent ED attendances and 30-day mortality (reflexive monitoring). Conclusions We found a high degree of variability between hospital sites, but no overall evidence that GPED increases the efficient operation of EDs or improves clinical outcomes, patient or staff experience. Trial registration number ISCRTN5178022.
British Journal of General Practice
BackgroundAround 43% of emergency department (ED) attendances can be managed in general practice. Strategies to address this include directing appropriate patients to GPs working in or alongside EDs (GPED). Views of GPs choosing to work in GPED roles may inform planning and implementation of GPED services as well as wider general practice provision.AimTo explore the experiences and motivations of GPs choosing to work in GPED services in England, and to identify factors that may support or hinder GPs working in GPED roles.Design and settingThematic analysis of 42 semi-structured interviews of GPs working in 10 GPED case sites across England.MethodQualitative GP interviews from a mixed-methods study of GPs in GPED roles were thematically analysed in relation to research aims.ResultsFour themes were generated: the ‘pull’ of a portfolio career; the ‘push’ of disillusionment with general practice; professional reciprocity; sustainability of GPED services and core general practice. Flexib...
General practitioners providing non-urgent care in emergency department: a natural experiment
BMJ open, 2018
To examine whether care provided by general practitioners (GPs) to non-urgent patients in the emergency department differs significantly from care provided by usual accident and emergency (A&E) staff in terms of process outcomes and A&E clinical quality indicators. Propensity score matched cohort study. GPs in A&E colocated within the University Hospitals Coventry and Warwickshire NHS Trust between May 2015 and March 2016. Non-urgent attendances visits to the A&E department. Process outcomes (any investigation, any blood investigation, any radiological investigation, any intervention, admission and referrals) and A&E clinical indicators (spent 4 hours plus, left without being seen and 7-day reattendance). A total of 5426 patients seen by GPs in A&E were matched with 10 852 patients seen by emergency physicians (ratio 1:2). Compared with standard care in A&E, GPs in A&E significantly: admitted fewer patients (risk ratio (RR) 0.28, 95% CI 0.25 to 0.31), referred fewer patients to othe...
Determining the true burden of general practice patients in the emergency department: Getting closer
Emergency Medicine Australasia, 2013
The issue of correct estimation of the number of patients who attend the ED with conditions that could be potentially managed by a general practitioner (GP) continues. The Australian Institute of Health and Welfare (AIHW) recently reported 2 176 612 ED attendances in 2012-2013 as potentially general practitioner (GP)-type presentations. 1 This represents one-third (32.4%) of all ED presentations and, we contend, significantly overestimates the numbers of this type of patient in AIHW annual Australian hospital statistics.
2013
Estimates of patients attending with conditions deemed non-urgent or inappropriate for accident and emergency services vary widely, from 6 to 80%. Previous research suggests that general practitioners (GPs) working in emergency departments can reduce referral rates, diagnostic testing, the proportion of patients who become emergency hospital admissions, and inappropriate attendances. However, little of this previous research is recent and new models of care for GPs working in emergency departments have now been developed, which remain to be evaluated. In this paper, we describe an integrated urgent care model, which was commissioned by NHS Hammersmith and Fulham in 2009 to manage the rising number of urgent attendances at local hospitals and its associated evaluation. The evaluation will include examining the effect of the system on outcomes such as utilization of diagnostic tests and effect on unplanned hospital admissions. If the new model of care is shown to be both clinically effective and cost-effective, the model and the proposed plan of evaluation will also be helpful to other areas that are considering the introduction of similar models of GP-led urgent care.
Prudent healthcare in emergency departments: a case study in Wales
Emergency Nurse
To deliver a patient-centred service Emergency Departments must be efficient, effective and meet the needs of the local population. Following the principles of prudent healthcare, a service redesign of unscheduled care was carried out at Prince Phillip Hospital, Llanelli to improve the patient experience. Extending the roles of specialist nurse practitioners was a major component of this redesign. Six working groups were established to guide the process, including one group with a responsibility for working cooperatively with the local community, who had concerns about perceived 'downgrading' of the Emergency Department. The service redesign was completed in 2016 and evaluation has shown that the target for patients being seen within four hours improved from 88% to 96%, significantly more acute medical admission patients were discharged in less than 24 hours and patient satisfaction increased overall.
Emergency medicine and "acute" general practice: comparing apples with 0ranges
Australian Health Review, 2000
Emergency Departments (EDs) operate at the interface between the inpatient and ambulatory sectors of health care. Because of shared funding between the Commonwealth and States for ambulatory care, there has been intense focus on the ED patient population, and the potential to shift the locus of care for non-inpatients.