Quality and productivity: auditing A&E attendance

Patient-initiated accident and emergency (A&E) attendances are an area of significant cost but where there is scope for GPs to influence patient behaviour to reduce avoidable attendances. Indeed GPs are encouraged to do this by the inclusion of A&E attendances in the current QOF quality and productivity (QP) indicators.

Reviewing attendances

A review of A&E attendances enables GPs to make an assessment of those patients who use the service inappropriately. Patient education at practice level is one way of changing their behaviour. Changing the practice’s opening hours to improve access might also help. A GP triage system located next to A&E could be another way of potentially reducing avoidable attendances.

While some practices may want to try their own strategies, there may be peer pressure to work together in your locality.

Two practices audited

Our audit looked at all the A&E attendances by patients from two very different GP practices in Oldham from 19 March to 16 April 2012 with a view to reducing unscheduled care (first and unplanned follow-up visits to A&E) by minimising avoidable attendances.

Specific objectives

These were to:

• Focus on three patients groups (as per the QP indicators guidance): older patients with co-morbidities at high risk of admission; children with minor illness/injury, and patients who frequently re-attend A & E who could be dealt with in primary care.
• Identify avoidable A & E attendances and re-attendances in these groups.
• Highlight the reasons for attendances and why they were avoidable.
• Identify alternative services available.
• Set standards for the future.

Audit results

The vast majority of unscheduled attendances could have been avoided, by using alternative services. Children with minor illness/injury were the largest group for both practices, accounting for 19% (practice A) and 20% (practice B) of total attendances.

In all, 21% of attendances could have been unnecessary if the patients had attended their GP practice instead (assuming they could have got same day appointments).  

Appropriate alternative services available include a walk-in centre that is open 7am to 11pm and is able to treat minor injuries and ailments. Using this service could have rendered 20% of practice A and 28% of practice B attendances avoidable.

There is also rapid access to certain services including those for stroke, suspected DVT/pulmonary embolism and pregnancy-related problems. Utilisation of rapid access could have made 20% of practice A and 9% of practice B attendances avoidable.

A common reason for A&E attendance was pain symptoms at 30% for practice A and 27% for B. Better pain management in primary care could have avoided these trips to A&E. Pregnancy-associated problems made up 15% of attendances for practice A and 4% for B: this could have been avoided by setting up an early assessment pregnancy unit.

Peak times

For both practices, the highest numbers of attendances were on Mondays and Fridays. The latter day is understandable as both practices close at the weekend, but why Monday when both open on Monday? With practice A, 15% of attendances were on Thursdays when it closes for half a day, so opening for the full day on Thursdays may help to reduce A&E attendances.

The majority of attendances - 67% at practice A; 62%, practice B - occur during surgery opening hours while 15% for practice A and 19%, for B were in the early hours of the morning when the only alternative would be the out-of-hours-service. 

Limitations and conclusions

As the audit data was obtained from hospital letters sent to the GPs, there was sometimes very limited information - usually a single sentence – making gauging the severity of the symptoms prompting the attendance difficult.

Despite this, the results of this small audit appear to us to make clear that most patient-initiated visits to A & E are avoidable.

In our view there is scope to significantly reduce them if patients obtain same-day appointments, go to the walk-in centre or use rapid access. But lack of patient awareness of these services may be the biggest hindrance to preventing unnecessary A & E attendance. Siting a GP triage service next to A&E to initially assess patients could also reduce attendance.

• Dr Anita Sharma is a GP in Oldham and Mohammed Zeshan is a 5th year medical student at Manchester University.

External link QOF Quality and Productivity (QP) Indicators
Supplementary QP guidance