A Qualitative Study on the Variables Affecting the Flow of Patients to General Practitioners in Emergency Rooms

Heather Brant^*
*Correspondence: Heather Brant, Department of Health and Life Sciences, University of the West of England, Bristol, UK, Email:

Keywords

Emergency rooms • Health systems • General practitioners

Introduction

The number of people visiting emergency rooms is rising globally, and a sizable share of these patients might be treated in general practise. In England, rules supported by significant capital financing mandate that these patients who visit emergency rooms be ‘streamed' to general practitioners who work alongside emergency rooms or in close proximity to them. However, there is little support for streaming, and nothing is known about how to stream patients from emergency rooms to general practitioners. As part of a larger mixed methods study, a longitudinal qualitative investigation was carried out using information gathered between October 2017 and December 2019 at 10 case study locations throughout England. The procedures and experiences of streaming were thematically analysed from 186 non-participant observations and 226 semi-structured interviews with 191 health professionals working in emergency departments or associated general practitioner services [1].

Description

Between October 2017 and December 2019, data were gathered. The majority of interviews with healthcare personnel took place face-to-face at the hospital case sites, with a small percentage (10%) performed over the phone at the participant's choice. The research team created a topic guide for semi-structured interviews that was based on the most recent research as well as the specific goals and objectives of the larger "General Practitioners and Emergency Departments - Efficient Models of Care" study. All participants received participant information pamphlets that included an explanation of the study's purpose. All participants provided written consent before having their interviews recorded. Interviews typically lasted 20 to 60 minutes. Audio recordings of the interview data were first transcribed. NVivo Version 12 was used to organise both of these and observational field notes. After becoming comfortable with the data, the study team created a wide coding strategy (supplementary material 3: Box 4). The data were then compiled into case site pen portraits at each time point and contrasted/compared across sites and time points. Throughout the study's three-year data collection and analysis period, the research team iteratively developed the coding framework and continually improved it. Practically speaking, this meant developing and refining themes through both individual thematic analyses by each research team member and group discussion during monthly project sessions [2].

To conceive, organise, and evaluate the larger study, ten public contributors with experience in emergency department services were involved. They contributed to the creation of the initial grant request and helped create important study materials. Our public contributors took part in workshops where the topic of pen portraits and anonymized interview transcripts from two research sites was explored, in addition to attending meetings of the external steering group. Contributors' analyses of the data were contrasted with the framework developed by the study team. Since their opinions broadly concurred with those of the research team, reaching consensus was not difficult. Streaming was seen by contributors as a crucial component of service provision. They brought up the crucial function of streaming nurses as a subject for sub-theme exploration [3].

A total of 31 possible informants from all three EDs were purposefully invited to participate, representing a mix of physicians and management. Email messages were used to get in touch with them, and they received a flyer describing the study. Three nurses, three managers, and fifteen doctors were all interviewed. The 15 doctors were divided into 10 consultants, 2 specialty registrars, 3 senior house officers, and 6 consultants in emergency medicine (four of whom worked on acute inpatient medical wards). One drawback of this study is that an equal distribution of information throughout the three EDs was not accomplished due to a varying response rate. However, some of the informants were able to since they had previously worked at various sites. 21 participants from three acute hospital trusts participated in semi structured interviews with us. 11 emergency department (ED) doctors, 3 ED nurses, 3 supervisors, and 4 inpatient doctors were among the participants. These roles covered a wide range of seniority. The important aspects found in the theoretical framework the authors constructed to explain admission decisionmaking were used to develop interview questions. Two separate researchers used framework analysis to capture, transcribe, and analyse interview data [4,5].

Conclusion

All of the interviews were conducted by IP. While working as an Academic Foundation Programme physician at the time of the study, IP had previously practised medicine in Site 2 and in the EDs of Sites 1 and 3. As a result, the study had access to some "insider knowledge" that improved the quality and validity of the data it collected and allowed for more candid conversations with the informants. However, due to IP's "insider knowledge" and prior work with eight of the informants in different positions, it was necessary to make a conscious effort to reduce any chance of bias or subjectivity being introduced in the interviews. Acute hospital admissions have increased during the previous ten years in the National Health Service, rising by 37% in England between 2002 and 2012. 1 A number of variables, such as an ageing and expanding population, which has led to an increase in illness prevalence, have contributed to this surge. 2 But this only partially explains the rise. By 2022, there could be 6.2 million more hospital bed days annually if admission rates keep increasing at the current pace. 2 Clinicians, administrators, and decisionmakers are under pressure to reduce the overall rise in hospital admissions, particularly for acute admissions that are judged preventable or needless.

Clinicians stated that this eliminates a potentially lengthy wait in the ED for patients to see a primary care clinician in the three EDs included in our study that had protocols in place to redirect primary care patients to scheduled appointments in community primary care services. According to a staff member, patients seem to find this acceptable because they can leave the office and still be seen by their local primary care provider the following day. As a result, they are more likely to feel as though they are receiving assistance rather than being directed to seek care elsewhere.

Acknowledgement

None.

Conflict of Interest

None.

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