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Referrals from ED to primary care

B7_emergencyIn a bid to reduce patient numbers Southern DHB announced this week that it would implement a new system in its Emergency department, where patients not deemed in need of urgent medical attention would be asked to see their GP instead.

Those unable to afford to see their GP would be issued with a voucher. Southern PHO would be the partnering community provider of GP services.

Southern PHO head, Ian Macara wasn’t keen to publicise the vouchers though:

”We don’t want to set up a free service – that all you’ve got to do is trot down to your local ED and get a voucher and away you go.” 

The new Southern DHB system proposes that a triage nurse (if comfortable to do so) would have a conversation with a patient and ‘encourage’ them to see a GP instead. If cost was a barrier a voucher could be issued.

Southern DHB says they are not turning patients away, merely “offering the patient the choice of an alternative treatment provider.”

NZNO was asked our view of the new system. Our answer is – it must comply with Ministry of Health guidelines on the interface with primary care.

Making sure every single New Zealander has access to Emergency Departments is a fundamental part of our public health system.

The decision to treat someone in ED or redirect them is a clinical decision with clinical and professional accountabilities for the health practitioner.  We all know what happens when something goes wrong!

According to the plan, the burden of this work will fall on registered nurses.  Our members were not part of the design of this local system and we fear they may be pressured to reach targets, either of acuity or numbers of patients seen in ED.

Not only that, but the system is counter to the Ministry of Health NZ guidelines on the interface with primary care, which includes the important proviso that ‘encouragement’ to leave ED and make an appointment with a GP instead should not occur at the triage stage of the process. Triage does not accurately determine the appropriateness of a patient’s condition for presentation at either the ED or primary health care.

The Ministry of Health guidelines also state that the NZ public will not be declined care in emergency departments.

If the system does not change at Southern DHB, patients will not receive the assessment/diagnosis that must happen before a decision is made, triage nurses will be at risk and their workload will increase greatly.  This is not good for patient safety.

Nurses should have been part of the planning for this process and now need to have education on the redirection process, including the understanding of professional accountabilities.

NZNO will be working with Southern and other DHBs to ensure patients and staff receive high quality care, where and when they need it. The College of Emergency Nurses NZ -NZNO is drafting a position paper to detail responsibilities. We’ll link to that when it is finalised.

Below are the relevant sections of Ministry of Health’s 2011 guidelines on the Interface with primary health care.

2. Referring patients from ED to primary health care for ongoing care

2.4  The extent of ED care prior to referral to primary health care will vary, but the guiding principles should be that sufficient assessment/care is undertaken so that ED staff are satisfied that the patient is clinically:

  • safe (a need for alternative or more urgent care does not appear to be needed);
  • comfortable (distressing symptoms are addressed); and
  • appropriate (sufficient diagnostic work-up has been done so that there is reasonable certainty that primary health care is best suited to continue the patient’s management).

4. Identifying and referring patients for whom primary health care is better suited to meet their needs

4.4  However, referral to primary health care may occur if further clinical assessment determines that primary health care is better suited to meet the patient’s needs. This clinical assessment must be over and above the usual triage process and should ensure that the criteria in paragraph 2.4 are met. In addition, referral to primary health care in this context must:

  • be facilitatory and not against the patient’s wishes (ED care should not be denied);
  • be based on a high level of comfort from the assessing clinician that referral is best for the patient (the assessing clinician must not feel any institutional pressure to ‘refer’ patients to primary health care and must be protected from any undue risk associated with the referral of patients); and
  • occur in the context of a responsive primary health care service (the patient must be able to be seen in primary health care in an appropriate timeframe for their condition).