Suitability of emergency department attenders to be assessed in primary care: survey of general practitioner agreement in a random sample of triage records analysed in a service evaluation project
Mary IW Thompson, Daniel Lasserson, Lloyd McCann, Matthew Thompson, Carl Heneghan
Objectives: To assess the proportion of ED attendances that would be suitable for primary care and the inter-rater reliability of GP assessment of primary care suitability. Design of Study: Survey of general practitioners’ agreement of suitability for primary care on a random anonymised sample of all ED patients attending over a one month period. Setting: Emergency Department of a UK Hospital serving a population of 600,000 Method: Four GPs independently used data extracted from clinical notes to rate appropriateness for management in primary care as well as need for investigations, specialist review or admission. Agreement was assessed using Cohen’s Kappa Results: The mean percentage of patients that GPs considered suitable for primary care management was 43% (range 38% to 47%). Kappa for agreement was 0.54 (95% CI 0.44 to 0.64) and 0.47(95% CI 0.38-0.59). In patients deemed not suitable for primary care, GPs were more likely to determine the need for specialist review (RR = 3.5, 95% CI 3.0 to 4.2, p<0.001) and admission (RR = 3.9, 95% CI 3.2 to 4.7, p<0.001). In patients assessed as suitable for primary care, GPs would initiate investigations in 51% of cases. Consensus over primary care appropriateness was higher for paediatric than adult attenders. Conclusion: A significant number of patients attending ED could be managed by GPs, including those requiring investigations at triage. Stronger agreement among GPs over place of care may be seen for paediatric than for adult attenders. More effective signposting of patients presenting with acute or urgent problems, and supporting a greater role for primary care in relieving the severe workflow pressures in ED in the UK are potential solutions.