This paper is intended as a guide for the providers of New Zealand’s hospital emergency department (ED) services for how they should relate to the primary health care sector, with particular reference to the Shorter Stays in ED Health Target.
The paper was developed by the Ministry of Health’s Shorter Stays in ED team with input from the Primary Health Care Implementation team.
Initial consultation on the paper was sought from the Ministry’s ED Services Advisory Group, the Australasian College for Emergency Medicine and the Royal New Zealand College of General Practitioners.
This was followed by wider consultation with the sector.
The key guiding principles of the paper are:
- Primary health care is the principal provider of both routine and urgent health care to the New Zealand population, providing continuity and coordination of health care for individuals. EDs provide episodic ‘crisis’ care for people who perceive the need for acute or urgent care, including hospital admission.
- While there can be overlap in those individuals who might initially present to primary health care or ED, EDs provide emergency medical care and not ongoing primary health care. As such, all attendances to ED should be regarded as a significant health event and all urgent health care should be provided within the framework that the patient will, as much as possible, receive their ongoing care from primary health care.
- Appropriate clinical information on any ED attendance should be provided promptly to patients’ usual primary health care provider. This will enable the primary health care provider to follow-up with the patient as required and emphasises that ED care is the management of a ‘crisis’ in the context of continuing care being provided by primary health care. A strong interface, including electronic links, between EDs and primary health care will facilitate the prompt and reliable sharing of patient information to ensure best patient care is provided.
- The process of triage in ED is designed and validated as an acuity tool. Triage does not accurately determine the appropriateness of a patient’s condition for presentation at either the ED or primary health care. Therefore, patients should not be ‘triaged away’ from the ED. However, further assessment over and above triage, may allow referral to primary health care if best suited to meet the patient’s needs.
- Overall the relationship between primary health care and ED should be of two distinct services which refer to each other where and when appropriate. In the same way as primary health care will refer a patient to any other hospital speciality, it will refer to the ED patients who require the expertise of the emergency medicine speciality or the facilities available at the local ED. In return, just as an ED will refer a patient with a perceived cardiac problem to a cardiology service, so will it refer a patient to primary health care if, after adequate assessment, it is clear that the ongoing management of their condition can best be provided by primary health care.
1. Defining the roles and relationship between ED and primary health care
1.1 Primary health care services are the principal providers of both routine and urgent health care to the New Zealand population.
1.2 Primary health care services offer individuals both continuity and coordination of care with the various other health care providers who might episodically manage their particular health needs.
1.3 Enrolment with a primary health organisation (PHO) through a primary health care provider, and ongoing management of an individual’s routine and urgent health needs by that provider, should be encouraged.
1.4 There are urgent health care needs that can be attended to in primary health care. However, the capability and capacity to care for urgent needs in primary health care, particularly after-hours, varies from place to place.
1.5 EDs provide episodic ‘crisis’ care for individuals who perceive the need for acute or urgent care, including hospital admission.
1.6 Although there can be overlap in the individuals who present to each service, primary health care and EDs see different populations of patients and provide different care with a different skill mix and focus.
1.7 District Health Boards (DHBs), EDs and primary health care should work together to ensure that their populations are informed about the differences between primary health care and ED care, the services that are available 24/7 and when to access each service.
2. Referring patients from ED to primary health care for ongoing care
2.1 All urgent health care should be provided within the framework that the patient will, as much as possible, receive their ongoing care from their primary health care provider.
2.2 EDs have relationships with other health professionals, which often include processes for the referral of patients. When the ED phase of care is completed and it is evident that the patient would be better served by continuing care under another service, the patient is transferred to that service after communication between ED staff and the staff of the other service. EDs should consider primary health care in a similar way so that the referral to primary health care is undertaken when it is evident that care would be better continued there.
2.3 In referring patients back to primary health care for ongoing care, EDs should be clear what the expectation is of primary health care. Good communication and relationships between ED and primary health care should support this and help to bridge the potential separation in time and distance between ED referral and continuing care in primary health care.
2.4 The extent of ED care prior to referral to primary health care will vary, but the guiding principles should be that sufficient assessment/care is undertaken so that ED staff are satisfied that the patient is clinically:
- safe (a need for alternative or more urgent care does not appear to be needed);
- comfortable (distressing symptoms are addressed); and
- appropriate (sufficient diagnostic work-up has been done so that there is reasonable certainty that primary health care is best suited to continue the patient’s management).
3. Connecting all patients back to primary health care following an ED attendance
3.1 Regardless of whether there is a direct need for ongoing care following an ED presentation, appropriate clinical information about the event should be provided promptly to the patient’s usual primary healthcare provider (preferably electronically). The primary health care provider can then determine what level of follow-up is required. The intention is to emphasise that the ED care was management of a ‘crisis’, either real or perceived, in the context of continuing care being provided by primary health care.
3.2 DHBs should consider improving the interface between EDs and primary health care services, particularly through electronic links, to facilitate the prompt and reliable sharing of patient information.
4. Identifying and referring patients for whom primary health care is better suited to meet their needs
4.1 Individuals usually present to the ED because they believe that they require hospital-level care.
4.2 Cost, timeliness of access, location and the ability to enrol with a provider, can be barriers to accessing primary health care which can lead individuals to present to ED as an alternative.
4.3 The process of triage in ED, using the Australasian Triage Scale, has been designed and validated as an acuity tool. That is, triage determines the degreeof urgency for care; it does not accurately determine the appropriateness of a patient’s condition for presentation at either the ED or primary health care. Therefore, patients should not be ‘triaged away’ from the ED and individuals should not be denied ED care.
4.4 However, referral to primary health care may occur if further clinical assessment determines that primary health care is better suited to meet the patient’s needs. This clinical assessment must be over and above the usual triage process and should ensure that thecriteria in paragraph 2.4 are met. In addition, referral to primary health care in this context must:
- be facilitatory and not against the patient’s wishes (ED care should not be denied);
- be based on a high level of comfort from the assessing clinician that referral is best for the patient (the assessing clinician must not feel any institutional pressure to ‘refer’ patients to primary health care and must be protected from any undue risk associated with the referral of patients); and
- occur in the context of a responsive primary health care service (the patient must be able to be seen in primary health care in an appropriate timeframe for their condition).
4.5 For most DHBs it is hospital processes and the ability to admit patients to wards that are the significant contributors to ED overcrowding and increased length of stay, rather than patients who could be served in primary health care. Therefore, implementation of this referral process should be seen as a long-term strategy to reset the expectations and understanding of the public about the respective roles and skills of both ED and primary health care, rather than as a short-term activity to improve performance against the Shorter Stays in ED health target.
5. Improving access to acute hospital services
5.1 Emergency medicine adds value to the care of a great many patients. However, there are some patients for whom it does not, for example: patients who are clinically stable, who do not require further urgent treatment or investigations, who have had any distressing symptoms addressed and for whom the need for admission to an in-patient speciality unit has been determined by a primary health care provider (or an ED clinician).
5.2 DHBs should endeavour to have systems which allow the timely movement of such patients to the in-patient speciality unit, without the need for undue time or duplication of clinical assessment in the ED. This may include the use of in-patient speciality admissions units, such as Medical Admissions and Planning Units, or direct admission protocols.
5.3 The development of alternative pathways through which patients can access acute services, such as access to diagnostics in the community and to ‘acute’ specialist outpatient clinics, may be an important contributor to managing acute demand.
5.4 Opportunities to reduce acute demand are likely to be found in improving the management of long term diseases and the delivery of health care and support services to the elderly.