Piloting data linkage in a prospective cohort study of a GP referral scheme to avoid unnecessary emergency department conveyance

Joanna M Blodgett,Kenneth Rockwood,David Ratcliffe,Duncan J Robertson

doi:10.1186/s12873-020-00343-w

Abstract

BackgroundUK Ambulance services are under pressure to safely stream appropriate patients away from the Emergency Department (ED). Even so, there has been little evaluation of patient outcomes. We investigated differences between patients who are conveyed directly to ED after calling 999 and those referred by an ambulance crew to a novel GP referral scheme.MethodsThis was a prospective study comparing patients from two cohorts, one conveyed directly to the ED (n = 4219) and the other referred to a GP by the on-scene paramedic (n = 321). To compare differences in patient outcomes, we include follow-up data of a smaller subset of each cohort (up to n = 150 in each) including hospital admission, history of long-term illness, previous ED attendance, length of stay, hospital investigations, internal transfers, 30-day re-admission and 10-month mortality.ResultsOlder individuals, females, and those with minor incidents were more likely to be referred to a GP than conveyed directly to ED. Of those patients referred to the GP, only 22.4% presented at ED within 30 days. These patients were more likely to be admitted then than were those initially conveyed directly to ED (59% vs 31%). Those conveyed to ED had a higher risk of death compared to those who were referred to the GP (HR: 2.59; 95% CI 1.14–5.89), however when analyses were restricted to those who presented at ED within 30 days, there was no difference in mortality risk (HR: 1.45; 95% CI 0.58–3.65).ConclusionsDespite limited data and a small sample size, there were differences between patients conveyed directly to ED and those who were referred into GP care. Initial evidence suggests that referring individuals to a GP may provide an appropriate and safe alternative path of care. This pilot study demonstrated a need for larger scale, methodologically rigorous study to demonstrate the benefits of alternative conveyance schemes and recommend changes to the current system of urgent and emergency care.

Highlights

IntroductionAs the number of 999 calls and the number of patients who present at Emergency Departments (EDs) increase each year [1], United Kingdom (UK) Ambulance services are under pressure to safely stream patients to alternative routes of care [2, 3]
United Kingdom (UK) Ambulance services are under pressure to safely stream appropriate patients away from the Emergency Department (ED)
Of the remainder 4540, 4219 (92.9%) were conveyed directly to the ED and 321 (7.1%) were referred to a General Practitioner (GP). Those who were referred to the GP scheme were older and more often female (64.2 ± 23.4 years old; 58.6% female) than those conveyed directly to the ED (57.6 ± 22.7; 51.1% female) (p < 0.001 for age and p < 0.01 for sex; see Table 1)

Summary

Introduction

As the number of 999 calls and the number of patients who present at Emergency Departments (EDs) increase each year [1], UK Ambulance services are under pressure to safely stream patients to alternative routes of care [2, 3]. A multidisciplinary clinical group at the North West Ambulance Service (NWAS) developed a triage protocol, Paramedic Pathfinder, to categorise patients into: emergency care, urgent and community supported care or self-care [10]. This system aims to reduce the number of unnecessary ED visits by directing paramedics to safe triage decisions that allow alternatives including urgent care centres and referral into primary care

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