Emergencies & GP after hours

Well there's an interesting article this week from Emergency Medicine Australia (Nagree et al 2012 'Telephone triage is not the answer to ED overcrowding' EMA 24 123-126) as well as a media release from the Australasian College of Emergency Medicine regarding triage.

Before rural medicine I was an EM trainee. I'm pretty passionate about emergency medicine - sadly one of the reasons I got out of the specialty was frustration with things I could not control, not least the phenomenon of 'access block' - too many people in the ED, waiting for beds on the ward. I must admit that as a junior doctor I would bemoan 'GP-type' patients clogging up the ED...but as time went on and I matured clinically, I realised that:

(a) these low acuity problems were quick and easy to fix
(b) they were not a burden on time or resources
and
(c) often even the low acuity patients had complex health needs that required admission to a hospital for sorting out.

As a rural doctor I do my utmost to avoid turfing patients unnecessarily to my overworked colleagues in the ED, trying to smooth my patients' admission to the appropriate unit without them having to be stuck on a trolley in the ED awaiting review.

Whilst it is tempting to imaging the ED clogged up with non-urgent problems, the reality is that such presentations are easily dealt with (even the most junior of resident medical officers can treat a UTI or reassure parents of a child with otitis media). What clogs up the ED are complex patients requiring investigation and admission, as well as the labour and resource-intensive presentations such as critical illness.

It's also relevant to the ongoing issue of what is and what isn't an emergency - with a blatant cost-shift between State and Federal funds trying to classify many ED attendees as 'inappropriate GP-type attendances'.

But there is a problem.

Politicians need to be seen to 'do something'. They have latched onto the concept of the idea of triage 4 and 5 patients as being GP-type attendees and in a non-evidence based approach have poured hundreds of millions into schemes such as GP after hours, co-located clinics and the disastrous healthdirect phone line.

Phone triage sounds good. But it doesn't work - experience from overseas (not least the ill-fated NHS-direct in the UK proves this). Put simply, a nurse or a GP following a protocol will not be able to diagnose over the phone 100% reliably. It may be a sop to the worried well, but my grandmother can do this job just as well and won't cost the estimated $200 million that healthdirect costs the taxpayer.

The Health Minister has stated that healthdirect has deterred 30,000 patients from a million calls from visiting the ED. Sounds good...but that's only 3% of calls...surely better to spend that money on beds and more clinical staff...not a phone service.

We don't do phone triage in the ED, instead advising patients to present to the ED for a face-to-face assessment - because it is a safe approach - history and examination cannot be done reliably over a phone. In fact, the more medicine I do the more I realise how medicine doesn't fall into neat protocols or boxes. The skill of a good Emergency Physician or GP is to spot the severely abnormal amongst the morass of mostly normal. A protocol (or my grandmother) will get things right most of the time - but will miss the more unusual or atypical presentations. The UK's NHS-direct has learnt this, with several lawsuits after missed diagnosis - the headache that was a subarachnoid, the febrile child with meningitis etc.

So Prof Nagree's paper neatly debunks the idea that phone triage alleviates pressure on Emergency Departments. What then of triage as a measure of ED vs GP-type attendances?

Triage is a score of urgency of treatment - not complexity. Many triage 4 or 5 patients have been sent to the ED by GPs. To then proclaim that they are 'GP-type' attendances misses the point that such patients are complex, require extensive investigation (usually using facilities not present in a GP surgery, such as X-ray, bloods etc) and often require admission.

This may not sound like a big deal - but it is an issue in the country where patients who are not admitted are charged a fee for attending the ED, on the spurious basis that they represent routine General Practice.

Which then raises the issue of GP After Hours services - what is the appropriate level of service needed after hours and will pumping money into GPAH alleviate pressure on EDs?

The Government clearly thinks so and is throwing around money like a drunken sailor. We met with the Medicare Locals mob last month on Kangaroo Island (formerly they were the Southern Division of General Practice in Adelaide, then GP-Network South, and now the unwieldy Southern Adelaide-Fleurieu-Kangaroo Island Medicare Local). They were canvassing opinion on GPAH services but seemed to have no grasp of the issues locally nor how to address them.

I always think of GPs like plumbers - you need us during working hours for scheduled things like routine maintenance...but we might have to deal with the occasional urgent job like a dripping tap. However you don't really need these things fixing at 3am. On the other hand, if the hot water service blows up or a water main bursts, this needs to be dealt with. These are the medical equivalent of an emergency medicine service and as rural GPs we provide this too. However is this routine GP or is this an emergency?

I'm a simple chap - I think that primary care generally deals with most things...but if it cannot wait 12 hours or needs the services of a hospital then the problem is ipso facto an emergency.

Nagree's paper establishes that phone triage does not alleviate pressure on EDs - the issue is access block, not inappropriate attendees. The corollary is that most patients are in ED because they belong there - throwing money at afterhours services by GPs doesn't really address their complex health needs requiring hospital services (imaging, same day bloods etc)

However the issue of non-admitted emergency patients remains unaddressed. I can cite numerous examples (not least from the current busy Easter weekend oncall as I type) of people presenting appropriately to the ED - but being forced to pay for their attendance because they are not admitted (State Govt cost shifts to Medicare)

Examples include

- fall from a roof, 25 cm incisional wound requiring formal debridement under local anaesthesia and repair taking 90 minutes

- fall from a horse with possible cervical spine injury

- four tourists in a medium speed (60kph) rollover on unsealed road, presenting to hospital for forensic blood alchohol, assessment of injuries

- 13 year old fall from skateboard with angulated Colles fracture requiring manipulation and casting

- mental health patient brought in by Police for assessment

- 45 yo with ?fracture-dislocation shoulder requiring analgesia, X-ray and reduction

All of these patients chew up a few hours of time. I think they were appropriately seen within the ED and not deferred for a routine 15 min GP appointment in the week.

However the false reliance on triage as a marker of GP vs ED attendance will continue to encourage misguided strategies to reduce ED overcrowding that are doomed to fail. It also allows cost-shifting from State (emergency) to Medicare (GP) budgets.

As ACEM say "it is in the political interest of State governments to ensure that any definition of general practice patients seen in EDs yields high numbers. This helps perpetuate the myth that EDs have too many GP patients'

Quite.

What do others think?