By Ida Warren,2014-12-13 12:01
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    A Process and Sorting Tool to Assist People to Access the Most

    Appropriate Urgent Health Care

    The Report from the Expert Advisory Group established by DHBNZ to consider the development of a Sector Disposition


    20 August 2007

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    The Expert Advisory Group, after considering the responses to the Discussion

    Document, recommends:

    1. That the Ministry of Health, ACC, DHBs, PHOs and Ambulance Services adopt the Client Pathway Algorithm for Urgent Care”, including the

    Decision Tool for Deciding if a Person can be managed appropriately in Primary Care Services”, nationally.

    2. Telephone Advice Services

    That the Ministry of Health ensure that:

    a. Telephone health advice services are further developed so that

    they are able to give advice to callers about where to get their

    urgent care, not just that they need urgent care.

    a. Telephone advice services use evidence-based decision support

    and are nationally consistent in standards but responsive to local

    circumstances; that they have an easily accessible, regularly and

    frequently updated database of the skills and technical resources

    available in different regions at different times of the day, and (since

    the clinical picture is rarely the determining factor) that they are

    able to offer choices when local conditions allow it.

    3. Ambulance Services

    a. That the Ministry of Health and ACC work with Ambulance Services

    to ensure that ambulance staff are trained to be able to assess

    whether the person they are working with could be better treated in

    primary care (either general practice or After Hours Medical

    Centres) or the emergency department.

    b. That ACC and Ambulance Services examine the funding

    mechanism for ambulance services to ensure that there are no

    perverse incentives driving ambulance staff to deliver people to

    emergency departments when they could receive appropriate care

    within primary care services

    4. Primary Care Services

    a. That each DHB produces an urgent care services plan, detailing

    the levels of urgent care it expects its primary care providers to

    deliver, and the level of integration expected between primary care

    and emergency departments

    b. That the Ministry of Health and ACC ensure that primary care

    providers receive the training they need so that they are skilled in

    the levels of urgent care that they are expected to deliver.

    c. That primary care providers are resourced with the equipment they

    need to deliver the level of urgent care expected from them

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    5. Emergency Departments

    a. That DHBs ensure that:

    i. The triage, assessment and referral roles of emergency

    departments are made clear to emergency department staff,

    with protocols produced to assist them to maintain their roles

    ii. Emergency department staff are trained to understand and

    assisted to trust the capability of the primary care sector

    b. That the Ministry of Health and DHBs work together to ensure that

    there are no legislative, service specification or customary practice

    barriers to a multidisciplinary workforce being fully empowered to

    utilise their competencies in urgent care services. An example of

    this might be a requirement in an emergency department that all

    patients be discharged by a doctor, when a nurse may have the

    clinical competence required.

    6. Social Marketing

    That DHBs and PHOs undertake a social marketing exercise to explain to the public and health professionals the interfacing roles of primary care and emergency departments in assisting people with urgent care needs

    7. Development Support

    That DHBs and PHOs work together to ensure that:

    a. There is a systematic and integrated approach to funding urgent

    care services, with funding silos not being used to drive perverse

    behaviours, but funding streams being combined where necessary

    to ensure integrated efficient service delivery

    b. The funding drivers of client behaviour are not ignored, but that

    models are developed in which client co-payments are a small part

    of the driver of behaviour in choosing care.

    c. That models of urgent services that have been developed in New

    Zealand, and which may offer useful approaches for DHB and PHO

    planners, are shared.

    8. Implementation

    The processes recommended by the Expert Advisory Group are based on a principled approach that should be the basis of all urgent care. Therefore the Expert Advisory Group does not see that these processes should be trialled, but rather that the processes should be adopted nationally. The Expert Advisory Group therefore recommends that:

    a. Three or four DHBs begin working on the development of a

    “Guideline for Urgent Care Services”, developing the proposed

    pathway and decision tool so that they provide detailed protocols

    for clinical staff to follow.

    b. DHBs then work with their PHOs to develop local solutions to how

    their services are structured to comply with the protocols.

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    a. DHBs instigate a process that enables DHBs with similar issues,

    such as rurality, to work together to develop practical solutions.

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    In November 2006, The Ministry of Health contracted District Health Board New Zealand (DHBNZ) to deliver a Sector Disposition Tool, defined as “A tool that will assist after hours professionals to determine which service (either primary care or the Emergency Department) patients should most appropriately attend for treatment for medical (and potentially accident) conditions”.

The Tool that is produced is required to be:

    1. appropriate for use in Emergency Department (ED) and primary health

    care settings, distinguishing different levels within primary health care;

    2. applicable to medical and accident conditions;

    3. safe for consumers;

    4. based on the best available clinical evidence and expert opinion;

    5. based on a consensus of ED and primary health care perspectives; and,

    6. a practical easy to use tool for the trained health professionals who use it.

    A key performance measure required by the Ministry of Health is that “the sector disposition tool receives support from key professional groups and stakeholders”. Therefore the development of the tool must ensure that stakeholders are engaged in a process that increases understanding of the issues and the solutions, and thereby acceptance of the final result.

    When an approach is agreed upon, then it will be trialled in some DHBs to be tested and refined before being further implemented.


    A group of sector experts in urgent health care issues met to develop a proposed approach that could then be consulted on. The approach they agreed on is attached as Appendix 1. This approach was sent out for feedback over June and July 2007. There were 22 submissions from organisations and 46 from individuals. The feedback was consistently supportive of:

    ; the sharing of appropriate information between primary care services and emergency departments

    ; integration as much as possible between services

    ; the use of multi-disciplinary teams

    ; public information about the appropriate use of emergency care and the value of attending primary care services

    Given the support for the above, the Expert Advisory Group has concentrated this report on establishing:

    ; client flow through urgent care,

    ; suggesting a decision tool that would assist a health professional to consider

    whether or not the patient needs ongoing care within emergency care or

    referral to primary care

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    ; identifying issues that need to be resolved for an integrated approach to be


    After considering the feedback, the Expert Advisory Group recommends that the following algorithm and Decision Tool be implemented in New Zealand. If the algorithm and Decision Tool are proceeded with, Guidance about how to use the process and tool would need to be developed.

The approach is based on the following premises:

    ; Primary care services are the prime providers of health care to the New Zealand population, for both routine and urgent care. Enrolment with a primary care provider, and ongoing management of non-urgent and urgent conditions by that provider, should be encouraged.

    ; Although there may be an overlap between Emergency Department and Primary Care, Emergency Departments provide different care, with a different skill mix, and focus.

    ; The transition between primary care and emergency department care should be as seamless as possible.

    ; Triaging is an assessment process to determine the degree of urgency required in delivering health care to a client.

    ; Triaging does not accurately determine the appropriateness of a client‟s condition for Emergency Department or Primary Care. Therefore, people should not be triaged away from emergency departments.

    ; Some emergency departments presented that their major issue is people who have attended emergency departments appropriately but cannot be referred on to inpatient hospital care because there are no beds available. That is, from their perspective a major restraint on emergency department resources is people who cannot be referred back to primary care and need inpatient hospital care. This view is not shared by everyone

    ; There is a perception that the motivation for commissioning this project was based on the premise that there is a major problem with inappropriate attendance at emergency departments by people who “should” be seen by primary care. The majority view of those who responded is that this is not a significant issue at most emergency departments, and that the capacity to manage patients who need hospital admission is a more significant contributor to ED overcrowding.

    ; However, it is acknowledged that emergency departments can provide a „safety net‟ function for certain populations who might not access primary care, e.g. street people, seasonal workers, migrants.

    ; It is also acknowledged that there are urgent care needs that can be attended to in primary care, and that what degree of care for urgent needs is available in primary care will vary from place to place.

    ; Emergency Departments have relationships with other health professionals, often including processes for referral of patients. When the emergency department phase of care is completed and it is evident that the patient would

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    be better served by continuing care under another service, then the patient is transferred to that service after communication (usually a phone call) between the emergency department staff and the staff of the other service. Emergency Departments should consider primary care in a similar way, so that referral to primary care is undertaken when it is evident that care would be better continued there.

    ; There will always be overlaps between primary care services and emergency departments, that is, people who could be seen in either. The recent article, “Can primary care patients be identified within an emergency department workload?, published recently in the New Zealand Medical Journal, makes it very clear that determining a patient‟s appropriateness for primary care when they are presenting for urgent care is difficult.

    ; Consequently , the Expert Advisory Group decided that a „tool‟ to direct people to Primary Care;

    ; Could not be a simple checklist

    ; Should only be applied after a health assessment

    ; Needed to be a „high level‟ tool, incorporating the

    competencies of the practitioner

    ; Should not deny access to care a client is seeking

    ; Should encourage referral to primary care when appropriate ; The diagram below attempts to visually represent the urgent care situation. When people do seek urgent health care, there are three main avenues. For primary care services and emergency departments the services required from each may vary according to resources available e.g. skilled personnel,

    technology. Availability of resources may be different within region according to factors such as rurality, size of city, etc.

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    All Urgent Care

    Primary Care Emergency

    Services Departments


    Given that the overlap between primary care urgent care services and emergency department services is a necessary feature of urgent care services given the variability of resources, the Expert Advisory Group recommends the following Client Pathway Algorithm for urgent care:

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    Person perceives need for urgent health care

     Person rings Person calls own Person calls

    telephone ambulance primary care provider

     disposition line

    Is management by Is management

    primary care provider by paramedics Self refers complete? complete? Self refers NO NO

    Is the person able to be managed by primary care services?

    Person needs more (taking into account the availability of after hours services

    e.g. overnight arrangements and the capacity of local primary care facilities specialist care beyond ED

    e.g. x-ray)

    YES NO

    Once person ‘s urgent

    care needs are met,

    given information about

    primary care as best Person referred to place for non-urgent and Emergency Department (ED) primary care service / ongoing support Referral ; ED triages for urgency Accident and Medical

    to ED if Centre

    required (with appropriate

    information and Patient receives health

    advice )about ongoing assessment

    treatment and support


    Does the person have urgent

    health needs requiring


    NO YES


    Continue Could the person be appropriately managed management in a primary care service? DRAFT 20.8.07 After Initial EAG& MOH Feedback in ED NO (* refer to the Sorting Tool for Guidance about

    9 of 15 how to make the decision)

Decision Tool for Deciding if a Person can be managed

    appropriately in primary care services

    NOTE: This decision is made by a health professional in the context of their training, scope of practice, professional experience and clinical expertise.


    Using your clinical judgement and knowledge of local resources, is this person presenting with a condition which is able to be managed by primary care services, or is management in ED necessary?



    1. Are primary care services available within a suitable time frame, e.g. After

    Hours Medical Centres?

    2. Are the technical resources that will be needed for this person available in

    your local primary care services, e.g. laboratory tests, radiology, clinical


    3. Does the person have access to transport that can take them to the primary

    care services?

    4. Will any other factors impact on the likelihood that this person will attend

    primary care services, e.g.

    a. isolation from services

    b. lack of ability to pay

    c. cultural factors, such as English as a second language, health beliefs?

    This tool can be expanded to serve the needs of individual health professionals within their scopes of practice.

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