Predictors of emergency department referral in patients using out-of-hours primary care services

ObjectivesOut-of-hours (OOH) primary care services are contacted in the last 4 weeks of life by nearly 30% of all patients who die, but OOH palliative prescribing remains poorly understood. Our understanding of prescribing demand has previously been limited by difficulties identifying palliative patients seen OOH. This study examines the volume and type of prescriptions issued by OOH services at the end of life.MethodsA retrospective cohort study was performed by linking a database of Oxfordshire OOH service contacts over a year with national mortality data, identifying patients who died within 30 days of OOH contact. Demographic, service and prescribing data were analysed.ResultsA prescription is issued at 14.2% of contacts in the 30 days prior to death, compared with 29.9% of other contacts. The most common prescriptions were antibiotics (22.2%) and strong opioids (19%). 41.8% of prescriptions are for subcutaneously administered medication. Patients who were prescribed a syringe driver medication made twice as many OOH contacts in the 30 days prior to death compared with those who were not.ConclusionAbsolute and relative prescribing rates are low in the 30 days prior to death. Further research is required to understand what occurs at these non-prescribing end of life contacts to inform how OOH provision can best meet the needs of dying patients. Overall, relatively few patients are prescribed strong opioids or syringe drivers. When a syringe driver medication is prescribed this may help identify patients likely to be in need of further support from the service.

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The impact of general practitioners working in or alongside emergency departments: a rapid realist review

BMJ Open ◽

10.1136/bmjopen-2018-024501 ◽

2019 ◽

Vol 9 (4) ◽

pp. e024501 ◽

Cited By ~ 6

Author(s):

Alison Cooper ◽

Freya Davies ◽

Michelle Edwards ◽

Pippa Anderson ◽

Andrew Carson-Stevens ◽

...

Keyword(s):

Primary Care ◽

Emergency Department ◽

General Practitioners ◽

Patient Experience ◽

Emergency Departments ◽

Care Facility ◽

Patient Choice ◽

Care Services ◽

Primary Care Services ◽

The Impact

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-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.ConclusionsMultiple 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 numberCRD42017069741.

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Taxonomy of the form and function of primary care services in or alongside emergency departments: concepts paper

Emergency Medicine Journal ◽

10.1136/emermed-2018-208305 ◽

2019 ◽

Vol 36 (10) ◽

pp. 625-630 ◽

Cited By ~ 3

Author(s):

Alison Cooper ◽

Michelle Edwards ◽

Janet Brandling ◽

Andrew Carson-Stevens ◽

Matthew Cooke ◽

...

Keyword(s):

Primary Care ◽

Emergency Department ◽

Emergency Departments ◽

Service Providers ◽

Routine Data ◽

Emergency Department Patient ◽

Classification Systems ◽

Care Services ◽

Primary Care Services ◽

And Function

Primary care services in or alongside emergency departments look and function differently and are described using inconsistent terminology. Research to determine effectiveness of these models is hampered by outdated classification systems, limiting the opportunity for data synthesis to draw conclusions and inform decision-making and policy. We used findings from a literature review, a national survey of Type 1 emergency departments in England and Wales, staff interviews, other routine data sources and discussions from two stakeholder events to inform the taxonomy. We categorised the forms inside or outside the emergency department: inside primary care services may be integrated with emergency department patient flow or may run parallel to that activity; outside services may be offered on site or off site. We then describe a conceptual spectrum of integration: identifying constructs that influence how the services function—from being closer to an emergency medicine service or to usual primary care. This taxonomy provides a basis for future evaluation of service models that will comprise the evidence base to inform policy-making in this domain. Commissioners and service providers can consider these constructs in characterising and designing services depending on local circumstances and context.

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