Primary care to emergency department: right service, right time, right place

Emergency department presentations continue to increase internationally and provide evidence that all is not well for health services and the populations they serve. In Australia, the equivalent of the combined populations of Brisbane and Adelaide presented to emergency departments with non-urgent conditions over a twelve-month period between July 2018 and June 2019. This study aimed to identify the health service requirements of patients presenting to a regional Australian ED with non-urgent conditions, and to translate findings into key recommendations and priorities for future health service planning. An explanatory sequential mixed method was used and involved three phases. The first phase was a descriptive and inferential analysis of seven years of routinely collected ED data to establish a profile of who presented to the ED with non-urgent conditions and when and why they presented. During the seven-year period 54.1% (n=165,399) of presentations were triaged as non-urgent. The second phase used a qualitative approach to conduct interviews with patients (n=9) and general practice staff (n=15). A thematic approach was used to analyse data. The final phase engaged key stakeholders and used a nominal group technique to translate research knowledge into recommendations and priorities for health service provision in Northern Tasmania. This study identified an over-representation in non-urgent ED presentations by young adults and children from the most disadvantaged suburbs, and a significant increase in mental health presentations over a seven-year period. An increasing proportion of presentations was observed to occur outside regular business hours. Interviews and focus groups highlighted a genuine perceived need for urgent care, at times driven by fear regarding symptoms. Patient interviewees did not consider the cost of primary care services to be a driver of their ED presentation; instead they demonstrated an understanding of the health system and identified limited access to primary care services. Service characteristics valued by patients were: clear communication, connection and comfort. In contrast, health professionals believed cost to be a major driver of non-urgent ED attendances and attributed patients with blame. A forum with key stakeholders from health services, academia, local government, community groups and a consumer representative identified key priorities for health service planning targeting local needs. Forum participants concluded that nurse practitioner and community paramedic roles in a primary health care setting could provide the right service at the right time and in the right place for this patient population, thereby reducing ED presentations. Participants identified that the 'ultimate model' would be located in the area of greatest need with an ability to provide outreach services and would include an interprofessional approach to health care provision. This service would be community led, driven and designed, and provide extended hours of service, seven days per week. This study provides a high quality example of how the explanatory sequential mixed method can be used to inform health service planning and policy. This method provides a strong framework in establishing the profile of who accesses the ED with non-urgent conditions and when and why they accessed them. Key findings were used to inform recommendations and priorities to address the needs of over-represented patient populations. The method used in this study provides a strong example for researchers internationally, who are working to address population health care needs.