Appropriateness of Referrals Made by Primary Care Professionals to the Hospital Emergency Department by Means of a Descriptive Study

Research Article

J Fam Med. 2020; 7(8): 1226.

Appropriateness of Referrals Made by Primary Care Professionals to the Hospital Emergency Department by Means of a Descriptive Study

Diaza V1, Justribo E2,3 and Yugueroa O1,3*

1Faculty of Medicine. University of Lleida, Spain

2Department of Primary Care Emergeny, Spain

3Doctor Pifarre Biomedical Research Institute of Lleida (IRBLLEIDA), Spain

*Corresponding author: Oriol Yuguero, Faculty of Medicine. University of Lleida, Avda Rovira Roure 80, 25198, Lleida, Spain

Received: July 31, 2020; Accepted: November 13, 2020; Published: November 20, 2020

Abstract

Objective: To determine the appropriateness of referrals made by primary care professionals to the Hospital Emergency Department by means of a descriptive study.

Location: Lleida Health Region.

Participants: Six hundred referral reports were evaluated from three separate periods, excluding paediatric reports.

Main measurements: Sociodemographic variables were collected from both the professionals and the referred patients. It was assessed whether the referral report was handwritten, if it included medical history, physical examination and diagnostic approach. It also considered whether the reason for referral and the result of the urgent process were included. In addition, it was checked whether the patient visited their primary care physician within 48 hours after discharge.

Results: Of the referrals made by primary care professionals, 85.7% were appropriate. The diagnostic correlation between the primary care professional and the Emergency Department was 73.7%. The main reason for referral was for evaluation at the hospital (92.3%). Of these, 82.8% required urgent complementary tests, the most common being chest radiography (35.5%) and blood analysis (27.8%). Following assessment at the emergency department, patients were predominantly discharged returning home (90.7%).

Conclusions: The level of diagnostic correlation is higher than previously described and referral reports are appropriate. However, there are some areas for improvement and we believe it is essential to provide more resources to primary care in complementary tests and training in traumatology to increase their resolution capacity.

Keywords: Diagnostic accuracy; Emergencies; Patient safety; Primary care; Quality of care; Resolution

Key Messages

- Referral reports from primary care professionals’ are appropriate

- The degree of diagnostic correlation between primary care and the emergency department is high

- The performance of additional tests is the main reason for referral.

- Resolution by emergency primary care centres is high

- Most referred patients return home after a complementary test is performed.

- Despite years of budget cuts, primary care resolution and diagnostic correlation have improved.

Introduction

Demand for Hospital Emergency Services (HES) has been increasing in recent years leading to the subsequent overloading of our health system’s emergency departments, to the detriment of both the HES themselves and for other care areas [1,2]. According to data from the Spanish Ministry of Health [3], the demand by emergencies at primary care centres (CAP) for 2017 reached 30 million and, specifically in Catalonia, 1.8 million.

Attendance at HES was 22.5 per 1,000 inhabitants in 2016 state wide and 3.8 in Catalonia [4].

While most patients who visit HES do so on their own initiative, the proportion of referrals by Primary Care (PC) physicians is not negligible, whether to conduct a diagnostic test to which the CAP does not have access, or to obtain a diagnosis and/or treatment [5]. Hence the critical role of these professionals to channel emergency demand and optimize the use of HES. In view of the high healthcare burden borne by HES, we believe it is important to perform a current review of referrals from primary care in our area by correlating the diagnoses of referred patients and those established upon their arrival at the emergency room so as in future, if necessary, to evaluate common protocols and procedures and thus reduce referrals of certain patients.

Recent studies analysing patient referral between primary care and a hospital in our country date from the beginning of 2000s [6]. Thus, after some 20 years, with changes not only of patients, but also with a generational renewal in the profession, we believe it is important to note whether changes exist not only in the number but also in the appropriateness of referrals.

In the province of Lleida, the Arnau de Vilanova University Hospital (AVUH) is a second level reference hospital for the entire province, where there is a daily average of 266 emergencies. These emergencies, in part, are referred by primary care physicians of the different Basic Health Areas (BHA), Primary Care Emergency Centre (CUAP) and out-of-hours care centres (PAC) in the La Noguera, Pla d'Urgell and Segarra regions. We therefore approach this study to determine the appropriateness of the referrals made by the primary care professionals of our region to the Hospital Emergency Department.

Material and Methods

This is a retrospective observational study of referral documents (p10) of patients who were referred to our hospital (HUAV Lleida). Two hundred referral documents were randomly selected in each period, September, November and December 2016, obtaining a total sample of 600 documents.

They included referral documents from health centres in Lleida city, from rural areas, from the CUAP and out-of-hours care centres around the health region. Referrals of patients under 16 years of age were excluded.

Variables

Sociodemographic variables were collected from both the professionals and the patients referred. Furthermore, the professional category of the person who made the referral was collected, as was the centre from which the referral was made.

Concerning the document itself, we recorded whether it was handwritten, if it included medical history, physical examination and diagnostic approach. We finally assessed whether the reason for referral was recorded in the document (evaluation, treatment or admission). Each referral report was evaluated according to AEP (Appropriateness Evaluation Protocol) standards [8].

We then performed an in-depth review of the report issued by the emergency department associated with the episode, which included the day of the week and time of admission to the emergency room, the assigned triage level, whether urgent complementary tests and/or a visit by a specialist were required, the diagnosis and time of and destination on discharge.

We finally checked whether the patient visited their PC physician for a check-up during the first 48 hours after discharge.

Statistical analysis

An anonymized database was set up recording all information on the medical histories reviewed. Numerical data were expressed using mean and standard deviation, or median and interquartile range, according to the distribution of the variable. Categorical variables were expressed using absolute and relative frequencies. Inferential analyses were not considered given the descriptive objectives of the study. Data were processed using the SPSS ver. 24 package.

Results

Of the referrals made by primary healthcare professionals, 85.7% were appropriate. The diagnostic correlation between the primary care professional and the emergency department professional was 73.7%.

Referrals from PC were made by medical professionals in 95% of cases, followed by nurses (4.3%) and occasionally by residents (0.7%). There is a predominance of professionals of female gender (64.4%). Referrals came from an urban BHA in 48.2% of cases, while rural BHAs referred only 25.8%. Referrals from other Rural Out-of-hours Care Centres accounted for 21.8% and only 4.8% came from the CUAP. The day of the week when most patients were referred is Thursday (20.5%) and Sunday (9.9%) the day with the least.

Of all patients, 52% (311) were women and 48% (288) men. The mean age was 57.68 years and comorbidity was low, given that the Charlson comorbidity index was 2.5.

Handwritten referrals accounted for 4.5% of all referrals. The patient’s medical history was included in 96.2% and in 89.8% of cases, the patient had undergone a physical examination while in 66.2% referral concluded with a diagnostic approach. (Table 1) sets out the reasons for referral.

Citation:Diaza V, Justribo E and Yugueroa O. Appropriateness of Referrals Made by Primary Care Professionals to the Hospital Emergency Department by Means of a Descriptive Study. J Fam Med. 2020; 7(8): 1226.