Cooper, Alison, Davies, Freya, Edwards, Michelle, Anderson, Pippa, Carson-Stevens, Andrew, Cooke, Matthew, Donaldson, Liam, Dale, Jeremy, Evans, Bridie Angela, Hibbert, Peter D., Hughes, Thomas C., Porter, Alison, Rainer, Tim, Siriwardena, Aloysius, Snooks, Helen and Edwards, Adrian (2019) The impact of general practitioners working in or alongside emergency departments : a rapid realist review. BMJ Open, 9 (4). e024501. doi:10.1136/bmjopen-2018-024501 ISSN 2044-6055.

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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.

Item Type:	Journal Article
Divisions:	Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School
Journal or Publication Title:	BMJ Open
Publisher:	BMJ
ISSN:	2044-6055
Official Date:	June 2019
Dates:	Date Event June 2019 Published 11 April 2019 Available 24 January 2019 Accepted
Volume:	9
Number:	4
Article Number:	e024501
DOI:	10.1136/bmjopen-2018-024501
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access (Creative Commons)
Date of first compliant deposit:	25 November 2019
Date of first compliant Open Access:	25 November 2019

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