Usual GP approach (perceived similar pre-test probability of serious disease) | If GPs who are experienced and confident in their clinical skills work in or alongside emergency departments without access to acute investigations, seeing patients identified as being appropriate for the GP service who they perceive are a similar cohort to usual primary care … | … they use their clinical skills to ‘rule out worst case’; are comfortable with uncertainty; use ‘safety netting’ techniques; and admit patients if they require acute investigation … | … to safely use a GP approach. | ‘The general theme we say to our GPs is we shouldn’t work any differently here than we would do if we sat in our practices , just because we’re in a hospital, we don’t do anything differently. If we need to admit people, we would obviously send them round as we normally would, in a practice, we’re not trying to be a mini A&E here and do anything differently.’ (GP, hospital 10, outside–onsite model) |
More cautious GP approach (perceived higher pre-test probability of serious disease) | If GPs who are experienced and confident in their clinical skills work in or alongside emergency departments with or without access to acute investigations, seeing a cohort of patients who they perceive to be higher risk … | … they incorporate this higher risk into their clinical decision making; consultations may be longer for more thorough history taking; the threshold for admission or using other acute services for investigation may be lower … | … but many patients can still be safely managed by using a GP approach. | ‘If you select the right patients to see, as a GP in the department, you should be able to deal with them in a similar way to you do in primary care , but always just having that slight radar on to think OK, is there something else going on , do we need to do that little bit more?’ (GP, hospital 14, inside–integrated model) |
Choose when to use a GP approach or an emergency department approach | If GPs with additional emergency medicine skills and experience work in emergency departments, seeing a wider range of patients with access to acute investigations … | … they can use their clinical skills to assess risk … | … to choose which patients can be safely managed by a usual GP approach, and which patients require acute investigation that they can manage using an emergency medicine approach. | ‘I tend to categorise patients into three groups: ones that I can see and treat and move on; ones that I see and need to admit or whatever I decide to do investigation wise, the decision is made early on; and then there’s the group in the middle where you’re uncertain whether this patient needs urgent admission or not, and you use the investigations as a tool to help in that decision making .’ (GP, hospital 3, inside–integrated model) |
Expectation to adopt an emergency department clinician approach | If GPs work in emergency departments with access to investigations, where there is an expectation to follow emergency department protocols, or governance responsibility is unclear, or patients may have already had investigations requested at triage … | … GPs may feel that they are expected to use these investigations in the emergency department setting, or they may become less confident in their clinical skills, or have medicolegal concerns … | … and may use investigations for patients that they would not have requested if they had seen the patient in usual primary care. | ‘Thinking about defence, if you don’t do tests when they’re right next to you, and something were to happen, an adverse event, you would have to be able to stand up to that and defend yourself and say why you didn’t do those tests, so it’s tricky, and I go through that all the time in my head’ (GP, hospital 14, inside–integrated model) |