ED I T O R I A L S
Primary care services and emergency medicine Drew B Richardson
Putting to rest the myth that emergency department overcrowding is due to a lack of primary care services
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ustralia’s emergency departments (EDs) are dangerously overcrowded, but a study by Buckley and colleagues in this issue of the Journal (page 448)1 should be the last nail in the coffin of the long-discredited myth that the root cause is a lack of primary care services. This study used a time series approach to identify a real — but clinically insignificant — change in ED workload after the opening of an after-hours primary care service in the New South Wales inland rural city of Wagga Wagga. The Australian public are entitled to receive high-quality and available care in both primary care and emergency settings, but the overlap between these services is not as important as many have claimed.2,3 In a rural location without pre-existing after-hours primary care services, the introduction of such a service, which treated 14 patients daily on average, was associated with an adjusted daily reduction in ED presentations of seven patients with an Australasian Triage Scale (ATS) category of 4 or 5 (lower urgency). As the authors note, because non-admitted low-urgency patients tend to have low resource needs, this reduction of 8% of total ED presentations would correspond to a lesser reduction in workload. Based on published Wagga Wagga Base Hospital data and accepted casemix measures, this reduction would translate to around 3% of this rural ED’s costs and no more than 4% of its ED medical and nursing staff time. These figures are higher than some other Australian estimates,4,5 mostly from studies in cities with pre-existing after-hours services. However, they remain consistent with the observation from these
studies that the overall weekly primary care workload in an ED amounts to no more than one patient per hour. In Wagga Wagga, few general practices open for more than 55 hours per week, and the after-hours service opens for 27 hours, but the ED is always open and is the only source of medical care in this community for more than half the 168 hours in each week. It is no surprise that some patients who could reasonably go elsewhere will present to the ED. Buckley et al’s results show that the after-hours clinic treated an average of 3.7 patients per hour. During the hours the clinic was open, the reduction in ED presentations was 1.8 patients per hour and, when it was closed (ie, the rest of the week), the reduction in ED presentations was 0.2 patients per hour. It is unlikely that extending the clinic’s opening hours would make much difference: opening during office hours would probably reduce presentations to existing general practices, and opening later at night would likely be uneconomical. Although, as the study authors note, general practitioners working in EDs in the United Kingdom have been shown to be more cost-efficient than junior medical staff in the same environment, the actual cost of emergency medicine is dominated by infrastructure and staff expenses 24 hours per day.6 EDs have a high average cost per patient and a low marginal (incremental) cost for additional low-acuity presentations, especially compared with off-site after-hours clinics, where expenses are dominated by medical labour, and the average and marginal costs are much
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closer together. Even if patients were 100% interchangeable, a new after-hours service would likely represent an increase in total cost to the community, because it would not reduce the need for the “public good” of a 24-hour service available at the hospital. Despite its limitations, this study confirms that “primary care patients” and “ED ATS category 4 and 5 patients” are not interchangeable. It is to be expected that there is some overlap between patients who might want to present to an ED and those who might want to go to a GP — just as there may be overlap between patients going to a GP or a gynaecologist for a Pap smear, or between those going to a thoracic surgeon or a respiratory physician for investigation of a lung mass. However, the finding that 96% of the weekly workload of an ED cannot be substituted by an after-hours service confirms that patients are largely presenting appropriately. By comparison, at least a third of average ED staff workload (and more than half in some places) consists of providing care to those who have completed their emergency treatment and are waiting for an inpatient bed,7 sometimes for days. Australian EDs are dangerously overcrowded with patients, many of whom should not be in EDs because they would be better managed elsewhere. But it is not the so-called primary care patients who are blocking ambulances from offloading8 — it is the “access block” patients waiting for beds on the inpatient wards who are inappropriately occupying ED space and staff time. Competing interests My unit has received research funding from the Australasian College for Emergency Medicine.
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Author details Drew B Richardson, MB BS(Hons), FACEM, GradCertHE, NRMA-ACT Road Safety Trust Chair of Road Trauma and Emergency Medicine Australian National University Medical School, Canberra, ACT. Correspondence:
[email protected]
References 1 Buckley DJ, Curtis PW, McGirr JG. The effect of a general practice afterhours clinic on emergency department presentations: a regression time series analysis. Med J Aust 2010; 192: 448-451. 2 AM (ABC Radio). Carr proposes setting up more GP clinics near emergency departments [transcript]. 2003; 18 Aug. http://www.abc.net.au/am/ content/2003/s926366.htm (accessed Mar 2010). 3 NSW Health. After-hours GP service supports Sutherland Hospital’s Emergency Department [media release]. 2009; 4 May. Sydney: NSW Government, 2009. http://www.sesiahs.health.nsw.gov.au/News_and_ Events/2009/20090504_AfterHoursGPService.asp (accessed Mar 2010). 4 Sprivulis P. Estimation of the general practice workload of a metropolitan teaching hospital emergency department. Emerg Med (Fremantle) 2003; 15: 32-37. 5 Sprivulis P, Grainger S, Nagree Y. Ambulance diversion is not associated with low acuity patients attending Perth metropolitan emergency departments. Emerg Med Australas 2005; 17: 11-15. 6 Duckett SJ, Jackson T. Paying for hospital emergency care under a single-payer system. Ann Emerg Med 2001; 37: 309-317. 7 Richardson D, Kelly AM, Kerr D. Prevalence of access block in Australia 2004–2008. Emerg Med Australas 2009; 21: 472-478. 8 Schull MJ, Kiss A, Szalai JP. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med 2007; 49: 257❏ 264.
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