Development and evaluation of a code frame to identify potential primary care presentations in the hospital emergency department

 
CONTINUE READING
University of Wollongong
Research Online
Australian Health Services Research Institute                                                                                 Faculty of Business

2019

Development and evaluation of a code frame to
identify potential primary care presentations in the
hospital emergency department
Heike Schutze
University of Wollongong, hschutze@uow.edu.au

Rhyannan Rees
University of Wollongong, St. George Hospital

Stephen Asha
St George Hospital, University of New South Wales

Kathy Eagar
University of Wollongong, keagar@uow.edu.au

Publication Details
H. Schutze, R. Rees, S. Asha & K. Eagar, "Development and evaluation of a code frame to identify potential primary care presentations
in the hospital emergency department", Emergency Medicine Australasia Online First (2019) 1-7.

Research Online is the open access institutional repository for the University of Wollongong. For further information contact the UOW Library:
research-pubs@uow.edu.au
Development and evaluation of a code frame to identify potential primary
care presentations in the hospital emergency department
Abstract
Objective: A major challenge in evaluating the appropriateness of ED presentations is the lack of a universal
and workable definition of patients who could have received primary care instead. Our objective was to
develop a standardised code frame to identify potential primary care patients in the ED.

Methods: A standardised code frame to identify which patients could potentially be treated in a primary care
setting was developed and tested on all patient episodes of care who presented to the ED of the St George
Hospital, Sydney, between December 2016 and February 2017. Sensitivity and specificity of the code frame
were performed. The code frame was then tested on all presentations from 2011 to 2016 in the St George
Hospital and The Sutherland Hospital in Sydney.

Results: Of 19 916 ED presentations, 5810 (29%) were potential primary care presentations. The code frame
had a sensitivity of 99.9% and a specificity of 49.0%. Results were consistent (28%) when applied to 5 years of
presentations (601 168 presentations).

Conclusion: This standardised code frame enables accurate retrospective local and national data estimations.
The code frame could be used prospectively to evaluate interventions such as diverting patients to primary
care settings, and to identify populations for specifically targeted interventions. The conservative nature of the
code frame ensures that only those that can safely receive care in a primary care setting are identified as
potential primary care.

Publication Details
H. Schutze, R. Rees, S. Asha & K. Eagar, "Development and evaluation of a code frame to identify potential
primary care presentations in the hospital emergency department", Emergency Medicine Australasia Online
First (2019) 1-7.

                                          This journal article is available at Research Online: https://ro.uow.edu.au/ahsri/974
Emergency Medicine Australasia (2019)                                                                       doi: 10.1111/1742-6723.13293

ORIGINAL RESEARCH

Development and evaluation of a code frame to identify
potential primary care presentations in the hospital
emergency department
Heike SCHÜTZE            ,1,2,3 Rhyannan REES,1,3 Stephen ASHA                   3,4
                                                                                       and Kathy EAGAR2
1
  School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia, 2Australian Health Services Research
Institute, University of Wollongong, Wollongong, New South Wales, Australia, 3St George Hospital, Sydney, New South Wales, Australia, and
4
  St George Clinical School, The University of New South Wales, Sydney, New South Wales, Australia

Abstract                                        5 years of presentations (601 168
                                                                                                  Key findings
                                                presentations).
Objective: A major challenge in                 Conclusion: This standardised code                • A major challenge in evaluating
evaluating the appropriateness of ED            frame enables accurate retrospective                the burden of patients who pre-
presentations is the lack of a univer-          local and national data estimations.                sent to the ED who could have
sal and workable definition of                  The code frame could be used pro-                   been equally treated in primary
patients who could have received                spectively to evaluate interventions                care, is the lack of a universal
primary care instead. Our objective             such as diverting patients to primary               and workable definition to
was to develop a standardised code              care settings, and to identify
frame to identify potential primary                                                                 identify these patients.
                                                populations for specifically targeted             • We developed a workable
care patients in the ED.
                                                interventions.    The      conservative             standardised code frame that
Methods: A standardised code frame
                                                nature of the code frame ensures that               can be used retrospectively or
to identify which patients could poten-
tially be treated in a primary care set-        only those that can safely receive                  prospectively,     to    identify
ting was developed and tested on all            care in a primary care setting are
                                                                                                    which patients could have
patient episodes of care who presented          identified as potential primary care.
                                                                                                    been seen in primary care. This
to the ED of the St George Hospital,                                                                robust tool will enable more
Sydney, between December 2016 and               Key words: ED, general practice,
                                                hospital emergency service, pri-                    accurate data estimations of
February 2017. Sensitivity and speci-
                                                mary care.                                          primary care appropriate pre-
ficity of the code frame were per-
                                                                                                    sentations in the ED, which
formed. The code frame was then
tested on all presentations from 2011
                                                Introduction                                        have not been previously pos-
to 2016 in the St George Hospital and           Presentations to the hospital ED are                sible. This will help planning
The Sutherland Hospital in Sydney.              consistently increasing worldwide                   and policy efforts.
Results: Of 19 916 ED presenta-                 and significantly outweigh population
tions, 5810 (29%) were potential                growth in Australia.1,2 The diversion           increased patient waiting times and
primary care presentations. The code            of specialist resources to presenta-            increased length of stay.3 Conversely,
frame had a sensitivity of 99.9% and            tions that could be better treated in           improved access to primary care
a specificity of 49.0%. Results were            primary care adversely affects the effi-        results in better use of health dollars,
consistent (28%) when applied to                cient performance of EDs, resulting in          continuity of patient care, reduced
                                                                                                waiting times and reduced pressure
                                                                                                on hospital acute services.4,5
Correspondence: Dr Heike Schütze, School of Health and Society, University of Wollon-             There is no standardised definition
gong, Northfields Avenue, Wollongong, NSW 2522, Australia. Email: hschutze@uow.                 of what constitutes a primary care
edu.au                                                                                          appropriate presentation either in
Heike Schütze, BSc (Biomed), MPH, PhD, Lecturer, Research Fellow; Rhyannan Rees,                Australia or abroad. A systematic
RN, Registered Nurse; Stephen Asha, BSc, MBBS (Hons), FACEM, MMed (ClinEpi),                    review of the literature6 found a sig-
Associate Professor; Kathy Eagar, BA, MA (Psych), PhD, FAFRM (Hon), Senior                      nificant variation in the calculation
Professor.                                                                                      methods used to report non-urgent
This is an open access article under the terms of the Creative Commons Attribution-             visits to the ED with rates ranging
NonCommercial-NoDerivs License, which permits use and distribution in any                       from 4.8% to 90%, indicating that
medium, provided the original work is properly cited, the use is non-commercial and             there is no standard method for
no modifications or adaptations are made.                                                       identifying or reporting primary care
Accepted 15 March 2019                                                                          appropriate patients in the ED.

© 2019 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College
for Emergency Medicine
2                                                                                                                H SCHÜTZE ET AL.

   Patients who present to the ED in          Hospital, a major trauma hospital in            The code frame was then tested on
Australia are classified according to         Sydney, Australia.                           all ED presentations from December
the urgency in which they must be                                                          2016 to February 2017 (19 916 epi-
seen using the Australasian Triage                                                         sodes of care). The criteria were
Scale (ATS):7
                                              Ethics approval                              applied as an algorithm in the order
• ATS 1 Resuscitation – seen                  The study was approved by the                listed in Table 1, for example, first all
   immediately                                South Eastern Sydney Local Health            ATS category 1–3 presentations were
• ATS 2 Emergency – within 10 min             District Ethics Committee, HREC              excluded as being considered a poten-
• ATS 3 Urgent – within 30 min                17/053 (LNR/17/POWH/146). Site-              tial primary care patient, then all
• ATS 4 Semi-urgent – within 60 min           specific approval was also obtained          patients who arrived by ambulance
• ATS 5 Non-urgent – within                   from the participating hospitals.            were excluded, and so on. Sensitivity
   120 min.                                                                                (the ability to detect true positives)
   This method has commonly been                                                           and specificity (the ability to detect
used to calculate non-urgent presenta-
                                              Data collection                              true negatives) testing were per-
tions considered to be appropriate for        ED presentations were reviewed for           formed.13 The hospital admission
primary care. The Australian Institute        the period December 2016 to                  code (that is, the code stating whether
of Health and Welfare (AIHW)                  February 2017 (19 916 records). De-          the patient was ultimately discharged
reported a primary care appropriate           identified medical record data were          from the ED or admitted into hospi-
presentation to be any patient allo-          provided in electronic form by the           tal) was considered to be the ‘gold
cated as an ATS 4 or ATS 5 category,          Electronic Medical Records Data              standard’ to assess whether a patient
who did not arrive by ambulance,              Manager.                                     was potentially suitable to be seen in
police or correctional services, was not                                                   primary care. Therefore, any patient
admitted to hospital and was not                                                           who was admitted to hospital was
referred to another hospital.8 How-
                                              Code frame development                       considered an ED appropriate presen-
ever, the ATS scale is an urgency scale,      An Advisory Committee was formed             tation (true positive) and those who
not a scale of the complexity of the          consisting of expert clinicians and          departed from the ED were consid-
case, which must also be taken into           researchers. The Committee com-              ered a potential primary care presen-
consideration, and the AIHW method            prised a Professor of Health Services        tation (true negative).
was shown to overestimate primary             Research, a Professor of General
care appropriate presentations.9 The          Practice, a General Practitioner, an
AIHW ceased reporting this statistic in       Associate Professor of Emergency
                                                                                           Results
2013 and stated that they would               Services Research, a Registered              Table 2 shows that 29% (5810 of
resume reporting primary care appro-          Nurse and a Research Fellow. The             19 916 episodes of care) were found
priate presentations if the estimation        Advisory Committee reviewed the              to be potential primary care
method was improved in the future.10          existing code frame for a primary            presentations.
   The lack of reliable and reproduc-         care presentation developed by                  The code frame had very high sensi-
ible criteria and methods for classify-       Bezzina et al.,12 who defined primary        tivity (99.9%) in that it identified
ing primary care presentations in the         care presentations as:                       patients who were ultimately admitted
ED results in unreliable estimations of       • ATS 4 or ATS 5 category                    to hospital and therefore not a primary
the      true    burden      of    these      • Self-referred                              care appropriate presentation, and the
presentations,6,9,11 and the need for a       • Presenting for a new episode               specificity was 49% it correctly identi-
robust workable method has been                  of care                                   fied those patients who departed and
highlighted.9 A standard definition of        • Unlikely to be admitted or ulti-           were therefore potential primary care
a primary care presentation is required          mately not admitted.                      patients (Table 3), when tested against
to achieve consistency in the interpre-          Next, the committee reviewed the          the hospital admission code.
tation of data and to provide a tool          code frame by Siminski et al.11 who             The code frame was then tested on
for identifying patients for targeted         added to this definition by including:       larger data sets to establish if results
interventions in the future. The aim of       • Did not arrive by ambulance                would be consistent. The code frame
the present paper is therefore to             • Presenting problem.                        was applied to all ED presentations
develop a code frame to identify                 However, Siminski et al. did not          from 2011 to 2016 at the St George
potential primary care presentations in       specify    what      the    presenting       Hospital (356 027 patient episodes
the hospital ED for these purposes.           problem(s) was/were, which did not           of care) and to The Sutherland Hos-
                                              lend the code frame to broader uni-          pital, Sydney (245 141 patient epi-
                                              versal application.                          sodes of care); 28.7% and 28.4% of
                                                 The Advisory Committee reviewed           presentations respectively were con-
Methods                                       all ED presentations during February         sidered to be potential primary care
                                              2017 (6313 presentations) and                presentations. These results were
Study design                                  adapted the code frame by adding             approximately 40% lower than cal-
Retrospective audit of hospital ED            and removing criteria as shown in            culations based only on ATS 4 and
medical records at the St George              Table 1.                                     ATS 5 codes.

    © 2019 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College
                                                                                                             for Emergency Medicine
CODE FRAME TO IDENTIFY PRIMARY CARE PATIENTS                                                                                              3

   TABLE 1. Criteria for defining a potential primary care presentation in the ED
   Criteria                                                                                                                   Action

   Low urgency and/or acuity, indicated by being classified as triage categories four or five on the Australasian            Retained
     Triage Scale
   Did not arrive by ambulance                                                                                               Retained
   Did not arrive by helicopter, police, community transport or internal transfer                                            Added
   Were self-referred                                                                                                        Retained
   Were not referred by aged care, community health, Department of Correctional Services, general practitioner,              Added
    health direct, mental health, other, other hospital, outpatient
   Presenting for a new episode of care, this information code is not available and is determined by the presenting          Removed
     problem
   Were not expected to be admitted, determined by ‘First Decision to Admit†’ code                                           Retained
   Did not have a Triage Speciality Mode of Care code‡                                                                       Added
   Presenting problem§ – not any of the following:                                                                           Added
   •   Abnormal results                                        •   Flank pain
   •   Assault                                                 •   Intoxicated persons
   •   Behavioural disturbances                                •   Mental health
   •   Bleeding in pregnancy                                   •   Other (as there is insufficient information to draw
   •   Chest pain                                                  a conclusion)
   •   Collapse                                                •   Overdose
   •   Confusion                                               •   Palpitations/abnormal heart beat
   •   Did not wait                                            •   Per vaginal (PV) bleed
   •   Depression                                              •   Self-harm
   •   Device care                                             •   Suicidal ideation
   •   Dislocation
   •   Fever in immunosuppressed patients

      †‘First Decision to Admit’ code is a code applied as soon as the treating clinician has made a decision to admit the patient.
   This usually occurs after the clinician’s clinical assessment but in some circumstances can occur earlier. This action alerts
   bed management to commence the process of bed allocation. ‡Triage Speciality Mode of Care refers to the triage nurse
   recognising that the patient’s presenting problem fulfils a pre-existing hospital management pathway protocol and activating
   that pathway. Examples include activating a trauma call if the patient meets trauma team activation criteria, or activating a
   stroke call if a patient falls within the eligibility criteria for stroke thrombolysis. §Presenting problems are pre-specified cate-
   gories in the electronic medical record system that the triage nurse selects to best describe the presenting problem.

Discussion                                    on ATS codes overestimate the                   solely on diagnosis are only useful
                                              degree of presentations.9 This is               for retrospective analysis. The code
Using our code frame, 29% of                  because the ATS is an urgency scale             frame used the ‘First Decision to
patients attending the ED were                and does not take into consideration            Admit’ code, which is an alert acti-
deemed suitable for primary care. This        the complexity of the patient’s case.           vated within the electronic medical
method builds on the code frames              Nagree et al.9 demonstrate this nicely          record as soon as the treating clini-
developed by Bezzina et al.12 and Sim-        by highlighting how an elderly                  cian had decided the patient needed
inski et al.11 by including the pre-          patient with a fractured forearm can-           to be admitted. This information is
senting problem, and expanding                not be safely discharged home with-             not available to the triage nurse at
arrival mode and referral source, to          out allied health support, but would            the time of arrival; however, it has
provide a standardised definition of a        not be considered high urgency on               been well documented that suitably
potential primary care presentation.          the ATS.                                        qualified and experienced triage
The code frame can be used to identify          Our code frame is a robust                    nurses can accurately predict those
potential primary care patients in the        method that can be used for triaging            patients who will need admission at
ED retrospectively.                           potential primary care patients                 the time of presentation.14–17 For the
   This method concurs with the               because it uses presenting problem.             purposes of the present study, we
findings that the calculations based          Although effective, methods relying             could only use data codes that were

© 2019 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College
for Emergency Medicine
4                                                                                                                H SCHÜTZE ET AL.

                                                                                           routinely collected and available ret-
    TABLE 2. Primary care presentations in the St George Hospital ED,                      rospectively from the database.
    December 2016 to February 2017                                                         Substituting the ‘First Decision to
                                                               No.           Balance
                                                                                           Admit’ code with the triage nurses
                                                                                           decision to admit potentially pro-
    Total presentations                                                      19 916        vides a systematic method to identify
                                                                                           primary care patients prospectively.
    Exclude triage categories 1–3                             10 903
                                                                                           This may allow for future interven-
                                                              10 903                       tions to redirect patients who could
                                                                                           safely be seen in primary care away
    Triage categories 4 and 5                                                  9013        from the ED. Redirecting non-urgent
    Exclude arrival mode                                                                   presentations to primary care has
      State ambulance                                           1233                       been shown to be effective in reduc-
                                                                                           ing non-urgent presentations in the
      Community transport                                            4                     ED and acceptable to patients.18
      Helicopter                                                     3                        The code frame is highly sensitive
      Wheelchair                                                     6                     in that it correctly identified a pri-
                                                                                           mary care appropriate presentation
      Internal ambulance transfer                                    9
                                                                                           99.9% of the time. Although the
      Police/correctional services                                22                       specificity was lower at 49%, it was
                                                                1277
                                                                                           deemed to be acceptable, especially if
                                                                                           the code frame was being used pro-
                                                                               7736        spectively, for it is prudent to err on
    Exclude source of referral                                                             the side of caution and see additional
                                                                                           primary care presentations in the
      Aged care                                                      4                     ED, as opposed to redirecting a
      Community health service                                       2                     patient with an urgent or complex
      Department of Community Services (DOCS)                        2                     condition to a primary care setting.
                                                                                           The conservative nature of the code
      GP                                                         401
                                                                                           frame extends to the fact that it takes
      Health direct                                                  2                     into consideration some patient
      Mental health                                                  3                     behavioural       characteristics     to
                                                                                           exclude patients from being consid-
      Other                                                          2
                                                                                           ered suitable for treatment in a pri-
      Other hospital                                                 6                     mary care setting. For example, a
      Outpatients                                                    4                     person with overt behavioural dis-
                                                                                           turbances or an intoxicated person
      Source of referral                                          27
                                                                                           may well be clinically seen in a pri-
                                                                 453                       mary care setting, but patients and
                                                                                           primary care providers may not be
                                                                               7283
                                                                                           comfortable with these people in
    Exclude First Decision to Admit                                                        their waiting rooms and often pri-
      Admit                                                      852                       mary care providers do not have the
                                                                                           resources to deal with disruptive
      Transfer                                                       4
                                                                                           patients.
                                                                 856                          Several factors influence a patient’s
                                                                                           decision to attend the ED, including
                                                                               6427        their perception of primary care,
    Exclude Triage Speciality Mode of Care                                                 being      able     to    get     timely
      Trauma call                                                    2                     appointments,19–21 convenience of
                                                                                           having diagnostic facilities and spe-
                                                                     2                     cialists at hand,19,20 age of the
                                                                               6425        patient and number of com-
                                                                                           orbidities.21 Consumer expectations
    Exclude presenting problem                                                             have changed over time with people
      Abnormal results                                            18                       seeking flexibility around work and
      Altered level of consciousness                                 1                     family commitments, while general
                                                                                           practitioners are demonstrating a
      Assaults                                                       9                     preference to work within normal
                                                                                           business hours because the financial

    © 2019 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College
                                                                                                             for Emergency Medicine
CODE FRAME TO IDENTIFY PRIMARY CARE PATIENTS                                                                                         5

                                                                                           incentives are not significant enough
   TABLE 2. Continued                                                                      to work in the after-hours period.22
                                                              No.           Balance           In addition, general practices differ
                                                                                           greatly in the services they can offer,
     Behavioural disturbances                                        3                     ranging from solo practitioners to
                                                                                           multi-practitioner health centres with
     Bleed, PV                                                   89
                                                                                           onsite X-ray, practice nurses and
     Blanks (did not wait)                                       20                        allied health. While EDs will always
     Collapse                                                        2                     continue to see potential primary care
                                                                                           patients, especially where alternative
     Device care                                                 43
                                                                                           facilities are not available, a robust
     Depressed                                                       3                     method for calculating the exact
     Injury, dislocation                                             9                     impact potential primary care patients
     Intoxicated                                                     1
                                                                                           have on ED performance can help
                                                                                           inform effective planning and policy
     Mental health problem                                       22                        decisions in the future. In areas where
     Other†                                                     197                        alternate facilities do exist, the code
     Overdose                                                        3                     frame offers a tool that can be used
                                                                                           at triage to redirect patients.
     Pain, chest                                                 40
     Pain, flank                                                 36
                                                                                           Strengths and limitations
     Palpitations/abnormal heart beat                                8
                                                                                           Our code frame provides a workable
     Pregnancy related                                          104                        standardised definition of a potential
     Self-harm                                                       4                     primary care patient and a
     Suicidal ideation                                               3                     standardised method to calculate how
                                                                                           many ED attendances were consid-
                                                                615                        ered safe to seen in primary care. This
   Total potential primary care presentations                                 5810         enables more accurate data estima-
                                                                                           tions nationally and provides a tool
   Category 4 and 5 presentations (%)                                            65        for comparing international trends in
                                                                                           both ED and primary care presenta-
     Subtotal values are in italics. †Other has been classified as not being primary       tions. This type of analysis requires
   care appropriate because insufficient data is available to deem it a primary care       consistent methods to identify pri-
   presentation.                                                                           mary care appropriate presentations.
                                                                                              Adding the Speciality Triage Mode
                                                                                           of Care adds an additional safety net
                                                                                           to capture any patients who may
                                                                                           have ‘slipped through the cracks’
                                                                                           through administrative error. For
   TABLE 3. Potential primary care presentation code frame sensitivity and                 example, Table 1 shows two patients
   specificity testing                                                                     were coded as Trauma calls on the
                                                Hospital admission
                                                                                           Specialty Mode of Care code. If only
                                                                                           the ATS codes were being used, these
                                                    code (%)
                                                                                           patients would have been counted as
                                            Admitted†      Departed‡      Total (%)        potential primary care patients
                                                                                           because they were actually miscoded
   Code frame result                                                                       as being lower urgency (ATS 4 or
                                                                                           ATS 5). Although these presenta-
     Admitted†
                                                                                           tions may well have been excluded
        Within hospital admission code           99.9          51.0          68.9          by presenting problem, this criterion
     Departed‡                                                                             adds an additional filter to improve
                                                                                           the sensitivity of the code frame.
        Within hospital admission code            0.1          49.0          31.1
                                                                                              Another strength is that the code
     Total                                                                                 frame uses the current presenting
        Within hospital admission code          100.0        100.0          100.0          problem classifications utilised by ED
                                                                                           staff when triaging patients. Consider-
     †Admitted = ED appropriate presentation. ‡Departed = potential primary                ing the terminology that is already
   care presentation.                                                                      used by ED staff, the adoption of the
                                                                                           code frame to prospectively identify

© 2019 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College
for Emergency Medicine
6                                                                                                                H SCHÜTZE ET AL.

and divert potential primary care             all EDs was beyond the scope of the            2.   Australian Bureau of Statistics.
patients in future interventions should       study.                                              3101.0 – Australian Demographic
be acceptable to staff. Considering                                                               Statistics, Dec 2017. Canberra:
primary care appropriate presenta-                                                                Australian Bureau of Statistics,
tions effect the within-hours period as
                                              Conclusion                                          2018.
much as the out-of-hours period, the          Our code frame provides a workable             3.   Forero R, McCarthy S, Hillman K.
code frame provides a valuable tool to        standardised definition of a potential              Access block and emergency depart-
do this.                                      primary care patient and a                          ment overcrowding. Crit. Care
   The list of presenting problems in         standardised method to calculate                    2011; 15: 216.
the code frame is based on the expert         what proportion of ED attendances              4.   Fry MM. Barriers and facilitators
opinion of the Advisory Committee             could potentially have been seen in a               for successful after hours care
after reviewing presenting problem            primary care setting. This will enable              model implementation: reducing
codes within the sample. The list is          more accurate national data estima-                 ED utilisation. Australas. Emerg.
not an exhaustive one and other pre-          tions, which are currently not avail-               Nurs. J. 2009; 12: 137–44.
sentations may need to be added in            able. It can be easily adapted to              5.   Nagree      Y,     Ercleve    TNO,
future. The code frame would include          incorporate triage codes to use in                  Sprivulis PC. Afterhours general
patients requiring simple procedures          international settings and provides a               practice clinics are unlikely to
such as an incision and drainage as           useful tool for comparing interna-                  reduce low acuity patient atten-
primary care appropriate; however, it         tional trends in both ED and pri-                   dances to metropolitan Perth emer-
should be acknowledged that in some           mary care presentations.                            gency departments. Aust. Health
practice situations primary care doc-                                                             Rev. 2004; 28: 285–91.
tors have less capacity to perform sim-                                                      6.   Durand AC, Gentile S, Devictor B
ple procedures, largely because of
                                              Acknowledgements                                    et al. ED patients: how non-urgent
time constraints. Our definition of pri-      The authors acknowledge and thank                   are they? Systematic review of the
mary care appropriate as defined by           Professor Andrew Bonney and Dr                      emergency medicine literature. Am.
our code frame may be less applicable         Marybeth MacIsaac who, along with                   J. Emerg. Med. 2011; 29: 333–45.
in practice situations such as this.          the authors, were part of the Advi-            7.   Australasian College for Emergency
   Our aim was to devise a code frame         sory Committee to develop the Code                  Medicine. Policy on the Austral-
that would capture patients who were          Frame. The authors also thank Cen-                  asian Triage Scale. Melbourne:
primary care appropriate acknowl-             tral Eastern Sydney Primary Health                  Australasian College for Emergency
edging that there will be inherent mis-       Network who funded this project.                    Medicine, 1993 [updated Jul 2013].
classification of a small number of                                                          8.   Australian Institute of Health and
cases that have somewhat unique                                                                   Welfare. Australian Hospital Statis-
                                              Author contributions
characteristics and low frequency that                                                            tics 2012–13: Emergency Depart-
the broad strokes of our code frame           HS and KE conceived the project                     ment Care. Canberra: Australian
cannot capture. An example would be           and obtained funding. HS coordi-                    Institute of Health and Welfare,
a procedure that required procedural          nated the project. RR and HS col-                   2013.
sedation such as a simple fracture            lected and analysed the data and               9.   Nagree      Y,     Camarda       VJ,
reduction, a condition that would not         drafted the manuscript. SA provided                 Fatovich DM et al. Quantifying the
be primary care appropriate. While            critical intellectual input in the clini-           proportion of general practice and
most cases would likely be excluded           cal aspects of the code frame and ED                low-acuity patients in the emer-
by triage category, there will still be       data. KE provided critical intellectual             gency department. Med. J. Aust.
some cases recorded as ATS category           input into the need for the code                    2013; 198: 612–5.
4 or 5 and not excluded by any other          frame. All authors were involved in          10.    Australian Institute of Health and
component of the code frame.                  the formation of the code frame. All                Welfare. Australian Hospital Statis-
   Regardless of whether the code             authors read and approved the final                 tics 2013–14. Emergency Depart-
frame is used retrospectively or pro-         manuscript.                                         ment Care. Canberra: Australian
spectively, it is limited by the ED                                                               Institute of Health and Welfare,
staff’s subjective assessment of each                                                             2014.
                                              Competing interests
patient and their classification of the                                                    11.    Siminski PM, Bezzina AJ, Lago LP,
patient’s presenting problem and tri-         None declared.                                      Eagar K. Primary care’ presenta-
age category. In addition, individual                                                             tions at emergency departments -
patient perceptions and preferences                                                               rates and reasons by age and sex.
                                              References
that drive their use of EDs have not                                                              Aust. Health Rev. 2008; 32: 700–9.
been taken into account and require            1.   Australian Institute of Health and     12.    Bezzina      AJ,      Smith      PB,
qualitative studies.                                Welfare. Emergency department                 Cromwell D, Eagar K. Primary
   The present study was limited to                 care 2014–15: Australian hospital             care patients in the emergency
two public hospitals in Sydney. It is               statistics. Canberra: Australian              department: who are they? A
likely that these results are                       Institute of Health and Welfare,              review of the definition of the ‘pri-
generalisable; however, testing across              2015.                                         mary care patient’ in the

    © 2019 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College
                                                                                                             for Emergency Medicine
CODE FRAME TO IDENTIFY PRIMARY CARE PATIENTS                                                                                         7

      emergency department. Emerg.                  disposition (EPOD) study. Aus-               professionals and patients. BMC.
      Med. Australas. 2005; 17: 472–9.              tralas. Emerg. Nurs. J. 2014; 17:            Res. Notes 2012; 5: 525.
13.   Webb P, Bain C, Pirozzo S. Essen-             161–6.                                 20.   Cheek C, Allen P, Shires L,
      tial Epidemiology: An Introduction      17.   Robertson-Steele IRS. Providing              Parry D, Ruigrok M. Low-acuity
      for Students and Health Profes-               primary care in the accident and             presentations to regional emergency
      sionals, 9th edn. New York: Cam-              emergency department: the end of             departments: what is the issue?
      bridge University Press, 2009.                the      inappropriate      attender         Emerg. Med. Australas. 2015; 28:
14.   Holdgate A, Morris J, Fry M,                  (Editorial). BMJ 1998; 315: 409.             145–52.
      Zecevic M. Accuracy of triage           18.   Buckley DJ, Curtis PW, McGirr JG.      21.   Australian Bureau of Statistics.
      nurses in predicting patient disposi-         The effect of a general practice             4839.0 – Patient Experiences in
      tion. Emerg. Med. Australas. 2007;            after-hours clinic on emergency              Australia: Summary of Findings,
      19: 341–5.                                    department presentations: a regres-          2015–16. Canberra: Australian
15.   Alexander D, Abbott L, Zhou Q,                sion time series analysis. Med.              Bureau of Statistics, 2016.
      Staff I. Can triage nurses accurately         J. Aust. 2010; 192: 448–51.            22.   Broadway B, Kalb G, Li J, Scott A.
      predict patient dispositions in the     19.   Durand AC, Palazzolo S, Tanti-               Do financial incentives influence
      emergency department? J. Emerg.               Hardouin      N,     Gerbeaux     P,         GPs’ decisions to do after-hours
      Nurs. 2016; 42: 513–8.                        Sambuc R, Gentile S. Nonurgent               work? A discrete choice labour sup-
16.   Vaghasiya MR, Murphy M,                       patients in emergency departments:           ply model. Health Econ. 2017; 26:
      O’Flynn D, Shetty A. The emer-                rational or irresponsible con-               e52–66.
      gency department prediction of                sumers?         Perceptions       of

© 2019 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College
for Emergency Medicine
You can also read