1. To which extent is GP referral to the Emergency Department appropriate? Heidi Michielsen, MD, MSc J. Hulens, MSc Promotor: Prof. M. Sabbe, MD, PhD Department of Emergency Medicine University Hospitals Leuven BELGIUM

2. 1. Context GP referralPatient self- referral Appropriate ED use?

3. “Can we blame the patients to not have enough knowledge to make the distinction between appropriate and non-urgent utilization when even professionals disagree on the urgency and the notion of appropriate visit?” Massin M. et al - 2002

4. 2. Methods What is ‘appropriate referral’? Prospective approach 1. Motive of referral + DDx (GP) 2. Triage code ESI 3. DDx (emergency physician) Scoring by 2 independent researchers No consensus?  expert panel KAPPA statistics

5. Operational definition Respiratory distress - need for oxygen therapy Shock NYD Acute chest pain Cardiovascular symptoms NYD Acute Abdominal pain Altered state of consciousness or responsiveness Progressive acute neurological signs, acute delirium or confusional state, not due to alcohol withdrawal Acute hematologic disorders Psychiatric emergencies (acute psychosis, suicidal ideation) Endocrine emergencies Sepsis, high fever with/without clinical focus, not decreasing with antipyretics or antibiotics Suspicion of severe traumatic injuries ESI code 1 or 2 at triage Need for specialist advise, investigations and/or interventions not available out-of-hospital Acute problem

6. 3. Results n = 187 t = 1 week 24,6% inappropriate referrals * Kappa = 95,8%

8. 4. Discussion Applied operational definition: Purely medical necessity of ED admissions 24,6 % “inappropriate” Possible explanations:  No inclusion of psychosocial or contextual factors.  Hiatus in current health care system?  ‘Out of hours’ access to technical examinations  Bypassing long waiting lists

9. 5. Conclusion Discrepancies in mutual expectations, attitudes and perceptions on appropriate ED use Further research: Link referrals to underlying motives of referring GPs