Emergency Department (ED) attendance has been shown to be a major predictor of re-attendance and further complications from worsening conditions, and is well-managed at the primary care level for those with chronic and multiple conditions. Older patients in particular are requiring a more complex model of care from their clinical team – especially if they are living within the community.

In a study conducted over five years across metropolitan Melbourne health services, it was uncovered that patients over the age of 70 were commonly presenting to emergency departments for conditions that could be treated by their general practitioners.

These potentially avoidable general practitioner (PAGP)-type presentations across the months and day of week reflect potential issues around the availability of GP services for older patients.

While a large number of such patients were presenting outside of regular practice hours between 6pm to midnight for external injuries such as wounds and those caused by falls, visits to emergency departments peaked in the late morning at around 11am for chronic and follow-up issues that required a triage rating of 4 or 5; and was not admitted to hospital.

Overall, the most common reasons for ED presentation were problems with eyes and ears.

Other peaks in ED attendance included weekends – with Monday, Friday and Saturday evenings recording higher presentations, and the traditional holiday periods of December to January also reflecting a seasonal variation in presentations.

The researchers from Monash University, Melbourne East General Practice Network, Royal District Nursing Service Institute and Gippsland Primary Health Network tracked the emergency department (ED) presentations of almost 750,000 people aged 70 years and over, according to condition.

However, it was noted that the majority of patients included in the study had arrived either by their own decision, or by the prompting of family or friends. Those residing in aged care facilities often arrive in emergency departments by hospital (thus removing them from this study), and have a better clinical support system in place.

The authors did note that during the study period of 2008-2012, after-hours GP care and locum services had been introduced to the area, which could account for the small decrease in PAGP-type ED presentations by older people. These initiatives alone were not enough to counter the issues observed in this wider study.

Older patients are increasingly attending EDs, with a proportion attending for problems that could potentially be managed in the general practice setting (termed PAGP-type presentations).

A low rate of referral back to the primary care setting implies a potential lost opportunity to redirect older patients from ED services back to their GPs for ongoing care.

Strategies within the ED have typically focused on the outpatient setting with the aim of reducing avoidable re-attendance by patients. These strategies have concentrated on issues around the development of individualised care plans, improving patient education about their own health care needs following discharge and coordination between emergency physicians and GPs.

Recommendations were developed for ED practice to improve communication with the patients’ treating GP, as only two-thirds of discharged patients were recorded as being referred back to their doctor at the time of discharge. These included optimised electronic discharge summaries and automated clinician prompting for such summaries – along with auditing and quality assessment tools.

Patients were also asked about their own behaviours, it was found that patients’ (and carers) understanding of what constituted an ‘emergency’ differed. In addition to health status and perceived quality of care, issues of access and other options influenced their decision to present at the ED.

The authors commented,

“Patients would prefer to see their regular GP rather than present to an ED.  Patients also prefer a ‘one stop shop’ for after-hours health services to minimise difficulties with transportation.

When made aware of alternatives to the ED, patients expressed support for a nurse practitioner visiting them at home (more so than a locum doctor).”