The impact of general practitioners working in or alongside emergency departments: a rapid realist review. Issue 4 (11th April 2019)

• Record Type: Journal Article
• Authors: Cooper, Alison; Davies, Freya; Edwards, Michelle; Anderson, Pippa; Carson-Stevens, Andrew; Cooke, Matthew W; Donaldson, Liam; Dale, Jeremy; Evans, Bridie Angela; Hibbert, Peter D; Hughes, Thomas C; Porter, Alison; Rainer, Tim; Siriwardena, Aloysius; Snooks, Helen; Edwards, Adrian
• Is Part Of: BMJ open. Volume 9:Issue 4(2019)
• Publication Date: 2019-04-11
• Subjects: emergency service, hospital -- primary health care -- general practitioners -- health services research; Medicine -- Research -- Periodicals; 610.72
• DOI: 10.1136/bmjopen-2018-024501
• Languages: English
• ISSNs: 2044-6055

Abstract

Abstract : Objectives: Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%–43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are 'free to care for the sickest patients'. However, the research evidence to support this initiative is weak. Design: Rapid realist literature review. Setting: Emergency departments. Inclusion criteria: Articles describing general practitioners working in or alongside emergency departments. Aim: To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system. Results: Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes. Conclusions: Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research. PROSPERO registration number: CRD42017069741.