To address the challenges around general practitioners referring patients unnecessarily to the ED, Nelson Hospital undertook a collaborative approach to pathway development, implementation, and enforcement. Nelson Hospital created referral pathways and established a hotline for general practitioners to use, allowing general practitioners to route their patients to the most appropriate care site. The following pages detail these two steps.
Develop care pathways to move patients to appropriate sites of care
Leaders at Nelson Hospital presented data to a multidisciplinary group of stakeholders that included leaders of local general practitioners. This data highlighted the variance that existed across general practitioners in terms of referrals to the emergency department, indicating the need for care pathways. A working group, which included general practitioners and hospital clinicians, was established to develop clinically-based care pathways. In the end, Nelson Hospital developed some 400 pathways, of which about 250 related to the emergency department.
These pathways were not created to limit how general practitioners practiced medicine, but rather to better support them in ambiguous situations. Room was still left for general practitioners to use their clinical judgement and pursue a different course of treatment. When a general practitioner does opt for something other than the protocol, however, a process also exists that gives them the opportunity to explain this alternative course of treatment.
Create a GP referral assessment line in the ED for consultation
The emergency department staff added an additional resource to help general practitioners navigate the various pathways that included a possible emergency department referral. Using an iPhone, the emergency department opened a direct phone line, connecting general practitioners to the most senior emergency department consultant on duty. The consultant serves as a reference, helping the general practitioner select the best course of care. In other words, this phone line allowed general practitioners to consult with an emergency department specialist before deciding to refer the patient to the emergency department.
They selected an iPhone for its portability. The senior most consultant carries it throughout the shift, making him/her accessible at all times. Because it is assigned to only one person at a time, the responsibility for responding to calls is clear.
Buy-in for this phone line was easily achieved: the direct and timely nature of the guidance resonated with general practitioners, while the ability to curb emergency department demand made garnering support from emergency department consultants straightforward.
Accountability reinforces adherence to guidelines
To ensure all of these new measures—from patient education to pathways support—were successful, Nelson Hospital also established protocols for dealing with patients and care providers who deviated from the expected course of action.
Patients who presented to the emergency department inappropriately were referred back to their GP. These patients were reminded that follow up care and any other low-acuity concerns should be taken to their general practitioners. For patients without a GP, staff requested that they find one and provided support to help with this task. By taking a proactive role in connecting patients to GP, ED staff have the opportunity to reduce demand for emergency services.
Similarly, senior ED consultants took an active role in ensuring GP pathway adherence: when a GP refers a patient in a manner not specified by the pathway, a senior consultant follows up with them to discuss the decision.
Together, these protocols function to decrease reliance on emergency service by routing inappropriate presentations to better sites of care.