Management of non-urgent paediatric emergency department attendances by GPs: a retrospective observational study

Simon Leigh; Bimal Mehta; Lillian Dummer; Harriet Aird; Sinead McSorley; Venessa Oseyenum; Anna Cumbers; Mary Ryan; Karl Edwardson; Phil Johnston; Jude Robinson; Frans Coenen; David Taylor-Robinson; Louis W Niessen; Enitan D Carrol

doi:10.3399/bjgp20X713885

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Drawing comparisons between co-located primary care and emergency department services within adult and paediatric care
Leila Mohammadi and Lauren Frame

Published on: 10 January 2021
Antibiotic prescribing by GPs in the emergency department
Kevork Hopayian

Published on: 07 December 2020

Published on: (10 January 2021)

Drawing comparisons between co-located primary care and emergency department services within adult and paediatric care
Leila Mohammadi, Medical Student, Keele University
Other Contributors:
Lauren Frame, Medical Student, Keele University
We read with interest this paper by Leigh and colleagues,¹ which sparked intrigue at the mention of limited supportive data from other studies. This enticed us to explore other papers regarding this topic in order to identify novel or unique features of the current study such that they could be reproduced. Upon doing so, we noticed that the common denominator appeared to be the differentiation between paediatric emergency department (ED) and adult ED services, with the former having notable beneficial outcomes compared to the limited findings from adult services.^2-5

On analysing the literature referenced from the current study we found that those conducted in a general ED setting had minimal benefit from the adjunct of a GP to the service. This was reinforced by our exploration of multiple studies that specifically focused on children’s ED services.^6-9These demonstrated significant increases in cost effectiveness and efficiency including reduced length of stay and admission rates. We recognise that this may result from parents being more likely to bring their child to the ED with non-urgent ailments.¹⁰ This coincides with findings from the current study that costs were reduced by almost 60% for children under 6 months.

Consideration should be given to the time frame of GP availability. The current study explicitly specifies the time period as 2pm-10pm. By and large, no mention is made of this in...
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We read with interest this paper by Leigh and colleagues,¹ which sparked intrigue at the mention of limited supportive data from other studies. This enticed us to explore other papers regarding this topic in order to identify novel or unique features of the current study such that they could be reproduced. Upon doing so, we noticed that the common denominator appeared to be the differentiation between paediatric emergency department (ED) and adult ED services, with the former having notable beneficial outcomes compared to the limited findings from adult services.^2-5

On analysing the literature referenced from the current study we found that those conducted in a general ED setting had minimal benefit from the adjunct of a GP to the service. This was reinforced by our exploration of multiple studies that specifically focused on children’s ED services.^6-9These demonstrated significant increases in cost effectiveness and efficiency including reduced length of stay and admission rates. We recognise that this may result from parents being more likely to bring their child to the ED with non-urgent ailments.¹⁰ This coincides with findings from the current study that costs were reduced by almost 60% for children under 6 months.

Consideration should be given to the time frame of GP availability. The current study explicitly specifies the time period as 2pm-10pm. By and large, no mention is made of this in other articles. Similarly, other papers reference walk-in centres without defining the associated personnel. Should other papers encompass these finer details, it could allow further and more precise parallels to be drawn, thus uncovering the salient features needed to improve integration of primary care into emergency medicine.

We propose that differences in patient age groups may explain why the original study reported incongruences with previous literature. Recognition of this fact as a possible explanation could influence future research and aid implementation of primary care resources in emergency medicine. To confirm this potential association, larger scale research into co-located primary care and ED services would be required with evaluation of the presence of successful programmes run within paediatric EDs.

References
1. Leigh S, Mehta B, Dummer L et al. Management of non-urgent paediatric emergency department attendances by GPs: a retrospective observational study. Br J Gen Pract 2020; 71(702):e22-e30.
2. Khangura J, Flodgren G, Perera R, Rowe B, Shepperd S. Primary care professionals providing non-urgent care in hospital emergency departments. Cochrane Database of Systematic Reviews 2012.
3. Cooper A, Davies F, Edwards M et al. The impact of general practitioners working in or alongside emergency departments: a rapid realist review. BMJ Open 2019; 9(4):e024501.
4. Salisbury C, Hollinghurst S, Montgomery A et al. The impact of co-located NHS walk-in centres on emergency departments. Emerg Med J 2007; 24(4):265-269.
5. Ramlakhan S, Mason S, O'Keeffe C, Ramtahal A, Ablard S. Primary care services located with EDs: a review of effectiveness. Emerg Med J 2016; 33(7):495-503.
6. Kmietowicz Z. Children seen by GP in emergency department less likely to be admitted, study found. BMJ 2017; j4644.
7. McCarron M, Burgess K, Gibbs S. G339(P) An evaluation of primary care streaming in a tertiary paediatric emergency department. Arch Dis Child 2019; 104:A138-A139.
8. Gritz A, Sen A, Hiles S, Mackenzie G, Blair M. G241(P) More under-fives now seen in urgent care centre than A&E- should we shift our focus? Arch Dis Child 2016;101(Suppl 1):A132.1-A132.
9. Gnani S, Morton S, Ramzan F et al. Healthcare use among preschool children attending GP-led urgent care centres: a descriptive, observational study. BMJ Open 2016; 6(6):e010672.
10. Ogilvie S, Hopgood K, Higginson I, Ives A, Smith J. Why do parents use the emergency department for minor injury and illness? A cross-sectional questionnaire. JRSM Open 2016;7(3):205427041562369.
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Competing Interests: None declared.
Published on: (7 December 2020)

Antibiotic prescribing by GPs in the emergency department
Kevork Hopayian, Professor University of Nicosia Medical School, Sessional GP, Suffolk, University of Nicosia Medical School
The authors are to be congratulated on having the inspiration to use the “natural experiment” of patients being diverted to the emergency department (ED) when a GP was not available. However, I wonder if, first, this is typical of most GP in ED services and second, if missing data may have reduced the reliability of the findings.

The comparator group were patients referred to the ED when a GP was not available. There were 5737 patients in the ED group and 8707 in the GP group, meaning that the GP service was unavailable for 39.7% of presentations. That is a very large proportion. How does it compare with services elsewhere in the country? I suspect that this service is not typical of the rest of the country so the generalisability of the findings are in doubt.

Eighteen per cent of ED group were excluded from the study because of missing data while only 3% of GP group were. The missing data may have nothing to do with the quality of care and might just represent different patterns of work and pressure but even so, despite adjustment for confounders, this huge differential exclusion reduces the reliability of comparing outcomes of the two services.

Competing Interests: None declared.