I tend to agree with Rowley on this one. One area where we run into problems is the sick patients who can slip through the net a bit with delays in assessment and particularly with delays in assessment by a more senior doctor. At its simplest this means a patient sent in with severe pain can wait longer before analgesia; more seriously it can mean delayed and inadequate resuscitation of patients with sepsis syndrome.
This is all an area that gets fairly tricky to discuss though as it is usual for people to get defensive about the quality of care from their own specialty, particularly when a shift of resources is suggested.
The other and even more controversial area is admission avoidance: it has been suggested that in some set ups a number of patients referred for admission by GPs can be managed without admission after assessment by an Emergency Physician. Very difficult to produce evidence on this though, and there is also the question in a case where a GP sends a patient for admission and someone else doesn't admit them, who is right. I've also come across a similar case being made for Emergency Department referrals being reviewed by a GP initially as an admission prevention strategy. My guess is that in both cases the type of doctor who is keen on seeing someone else's referrals as an admission prevention strategy tends to be the kind who takes pride in avoiding admissions and as such has a relatively high threshold for admission. Whether thresholds are already too high or too low is another question.
Matt Dunn
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