From emergency department to general practitioner: Evaluating emergency department communication and...

ORIGINAL RESEARCH

From emergency department to generalpractitioner: Evaluating emergencydepartment communication and service togeneral practitionersNigel Lane and Matthew J BraggEmergency Department, Prince of Wales Hospital, Sydney, Australia

Abstract

Objective: To survey general practitioners’ (GPs) opinions of communication and service receivedfrom the ED of a tertiary metropolitan hospital.

Methods: Analysis of a postal survey form sent to 380 GPs in the hospital catchment area.

Results: One hundred and forty-seven completed questionnaires (39%, 95% confidence interval [CI]34–44%) were returned. Seventy-eight GPs (53%, 95% CI 45–61%) endorsed the currentmethod of discharge letter delivery by patient; however, 43 (29%, 95% CI 22–37%) statedthat letters were often not received. The most commonly proposed alternative to patientdelivery was facsimile transmission. One hundred and thirty respondents (88%, 95% CI83–94%) rated the overall standard of communication from ED as average or better;however, 64 (44%, 95% CI 36–52%) felt that important information was omitted from thedischarge letter. One hundred and seventeen (79%, 95% CI 73–86%) GPs found the EDadmitting officer role useful when referring patients. Fifty-nine (40%, 95% CI 32–48%)respondents cited difficulties accessing investigation results. The predominant source ofpatient dissatisfaction reported by GPs was excess waiting times.

Conclusions: Half of GPs surveyed supported the current system of patient delivered discharge lettersand of those who did not the majority preferred faxed discharges. There was little supportfor email communication. GPs reported problems with the current communication systemincluding discharge letters not reaching GPs and deficiencies in the discharge information.GP reported substantial difficulties in accessing outstanding investigation results. MostGPs felt that assessment and treatment of their patients in the ED was of above averagequality, as was the overall service they received from the ED. There was GP support for theED admitting officer role.

Key words: communication, continuity of patient care, emergency medicine, family practice, questionnaire.

Correspondence: Dr Matthew Bragg, Emergency Department, Prince of Wales Hospital, Randwick, NSW 2031, Australia.Email: [email protected]

Nigel Lane, MBChB, Senior Resident Medical Officer; Matthew J Bragg, Bmed, DRACOG, FACEM, Emergency Physician.

doi: 10.1111/j.1742-6723.2007.00983.xEmergency Medicine Australasia (2007) 19, 346–352

© 2007 The AuthorsJournal compilation © 2007 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

mailto:[email protected]

Introduction

Communication between hospital ED and the generalpractitioner is important in ensuring continuity andquality of patient care.1 This is complicated in a health-care system where patients may not be linked to a singleprimary care provider. Although it has long been knownthat GPs wish to be informed when their patients haveattended an ED,2 it is less well established what addi-tional information is most useful, and how best it isdelivered.3–5 Current practice in most Australian ED isfor the patient to be given a discharge letter to inform theGP of the patient’s attendance. This method relies on thepatient acting as a postman, and while it gives the patientresponsibility for their own health decisions it mightresult in the letter not reaching the intended recipient.6

Facsimile (fax) transmission of ED discharge letters hasbeen successfully trialled in some centres,7 but there areproblems regarding data confidentiality and patientconsent to transmission of this information.8 Asidefrom the mode of delivery there are questions aboutthe quality of information contained in ED dischargeletters, including computer generated letters.9 Previousstudies have also evaluated the quality of GP referralsto ED,10–13 GP satisfaction with the ED service,3 and theideal information GPs require from an ED.2

Our aim was to assess the quality of communicationfrom ED to GP at our institution, by surveying GPs’opinions regarding the preferred method and content ofwritten and telephone communication with our ED, aswell as the ED service provided to their patients.

Methods

An analytical cross-sectional survey was conductedfrom the ED of the Prince of Wales Hospital, Randwick,NSW, Australia. All information gathered was in refer-ence to this department. The study was conductedbetween May and July 2006. Research approval wasgranted by the hospital Research Ethics Committee. Asurvey form comprising 15 questions was specificallydesigned by the authors and included a mix of tick boxgraded response questions and others that allowed freetext entry. Five-point responses were used for scalequestions. The questionnaire was designed as an audittool but was not formally validated. It was estimatedthat over 80% of GPs in our hospital’s catchment areawere members of the relevant Divisions of General Prac-tice, who provided address labels for correspondence. It

was these GPs who became the study population. Thequestionnaire was posted out on the same day alongwith a reply-paid envelope to the 380 GPs in our insti-tution’s catchment area. Reminder letters were sent onceto all 380 GP 3 weeks after initial mail-out. The GPswere asked to keep all of their replies anonymous.

The questionnaire asked GPs how quickly theyreceived the ED discharge summary, and what theirpreferred method of delivery was. We also asked themto rate the quality of written communication from ourED, quality of patient assessment and treatment as wellas quality of service received. Because of anecdotal evi-dence an evaluation of the clarity of suggested follow upin the discharge letters and the ease with which GPswere able to access outstanding investigation resultswas sought. Additionally, we wished to know what theGPs’ preferred method of referral to the ED was andhow useful they found the ED admitting officer role.The admitting officer is a senior emergency medicalstaff member who provides a point of contact for refer-ring doctors. The final survey question was a free textresponse asking for suggested improvements to com-munications from our ED.

Responses were number coded for ease of interpreta-tion. Data were collated using Microsoft Word Excel(2003).

Results

The survey response rate was 147 questionnairesreceived from 380 sent (39%, 95% confidence interval[CI] 34–44%). Respondent ages ranged from 31 to87 years (mean 53 years) and in practice from 3 to62 years (mean 25 years).

As many survey forms contained at least one ques-tion that was not answered and some questions withmore than one response the totals do not always equal147.

Seventy-seven of our GPs (52%, 95% CI 44–60%)respondents said that they usually received the dis-charge summary within a week of the patient leavingthe ED; however, the range was considerable (Fig. 1).Twenty-nine per cent (95% CI 22–37%) of GPs felt theyoften or usually did not receive a discharge letter fromED. Fifty-three per cent (95% CI 45–61%) of GPs agreedwith the existing method of discharge letter delivery. Ofthose who preferred an alternate method, 76% (95% CI68–85%) wanted faxed discharges, whereas only 9%suggested email (95% CI 3–14%). The main reasonsgiven against patient delivery of discharge letters were

From ED to GP

347© 2007 The AuthorsJournal compilation © 2007 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

unnecessary delay and the likelihood that the letterwould be lost. Indeed, one GP commented ‘I think it isimportant to give people control over their health-caremanagement, but many will appreciate an offer to fax itto us because they know they are likely to lose it!’

One hundred and thirty GPs (88%, 95% CI 83–94%)judged the standard of written communication asaverage or better (Fig. 2), with 58% (95% CI 50–66%)rating it as good or excellent.

One hundred and seventeen GPs (80%, 95% CI73–86%) rated the quality of patient assessment in EDas good or excellent, and 122 (83%, 95% CI 77–89%) feltthat the treatment received was either good or excellent.The overall departmental service provided was felt to beaverage or better by 136 GPs (93%, 95% CI 88–97%),with 23 judging it as excellent (16%, 95% CI 10–22%)(Fig. 3).

The clarity of ‘patient follow-up requests’ such asarranging outpatient appointments or checking on out-standing imaging results was felt to be below averageor poor by 13 respondents (9%, 95% CI 4–13%).GPs nominated the most difficult requests in the dis-charge letter as arranging outpatient appointments and

following up outstanding pathology or imaging results(Table 1). This can be illustrated by the comments wereceived: ‘When things can be done easily in hospital, itis difficult when the ED expects GP to coordinate 10different things in the community’. Another said thatalthough it was difficult to organize specialist follow up:‘I believe this should be my job.’

Although 45 GPs (31%, 95% CI 23–38%) found therewas never or rarely any information missing from thesummary, for the remainder who answered the threemain areas of omission were; pathology and imagingresults, clear follow-up instructions, and changes tomedications or updated current medications (Table 2).Forty per cent (95% CI 32–48%) of GPs experienceddifficulty accessing outstanding investigation results,the most commonly cited reason for this being difficultyin getting through and protracted holding on the phone.However, only two GPs suggested internet access toinvestigation results as an answer, albeit this was a freetext survey question.

Most GPs (71% of responses, 95% CI 65–78%) per-ceived that long waiting times gave their patients thegreatest dissatisfaction with ED. Poor communicationbetween ED staff and patients, and poor staff attitudewere much less commonly cited as a cause of patientdissatisfaction (Table 3). Conversely, quality of care ortreatment (43% of responses, 95% CI 35–51%) andstaff courtesy and attitude (21% of responses, 95%CI 14–27%) were perceived to give patients the mostsatisfaction (Table 4).

When referring patients to the ED, most GPs statedthey used a combination of communication strategies.Fifty-nine per cent (95% CI 51–66%) reported contact-ing the ED admitting officer and 20% (95% CI 14–27%)involved the relevant inpatient service. Thirty-six percent (95% CI 28–44%) of GPs sent a letter with thepatient as well as phoning the ED admitting officer, and

32

45

28

21 21

0

10

20

30

40

50

1 to 2 3 to 6 7 to 14 >14 No response

Days

No.

res

pons

es

Figure 1. How long before general practitioners receive EDdischarge letters?

12

73

45

116

00

1020304050607080

Excellent Good Average Below Poor No response

Quality of communication

No.

res

pons

es

Figure 2. How do general practitioners rate the quality ofwritten communication from the ED?

23

83

30

81 2

0102030405060708090

Excellent Good Average Below Poor No responseQuality of service

No.

res

pons

es

Figure 3. How do general practitioners rate the overall qualityof service received from the ED?

N Lane and MJ Bragg

348 © 2007 The AuthorsJournal compilation © 2007 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

23% (95% CI 16–29%) sent a letter only. Only 10%(95% CI 5–15%) of GP stated they regularly used faxadmission referrals.

Eighty per cent (95% CI 73–86%) of respondentsfound the ED admitting officer a useful contact, but 48free text responses (29%, 95% CI 22–36%) described

negative experiences with the admitting officer system,including delays in speaking to the admitting officer,unhelpful attitude and lack of bed availability. Indeed,there was some degree of misconception as to theadmitting officer’s role: ‘On occasions the admittingofficer does seem not to be the medical officer who

Table 1. Most difficult requests in ED discharge letters

Category Responses Percentage (95% confidence interval)

Never had difficult request 24 16 (10–22)Arrange outpatient appointments 28 19 (13–25)Follow-up investigations 23 16 (10–22)Illegible writing 6 4 (1–7)Arrange residential care 2 1 (-0.5–3)Arrange urgent investigations 2 1 (-0.5–3)Authority prescription 2 1 (-0.5–3)No clear discharge plan 7 5 (1–8)No response 53 36 (28–44)

Total 147 100

Table 2. Information perceived missing from ED discharge letters


No information missing 45 28 (21–35)Unspecified information missing 3 2 (0–4)Clear discharge plan 18 11 (6–16)Investigation results 21 13 (8–18)Medication change 13 8 (4–12)Clinical data 10 6 (2–10)Name and seniority of ED doctor 6 3 (1–7)Diagnosis 5 3 (0–6)Other 2 1 (0–3)No response 38 24 (17–30)

Total 161 100

Table 3. General practitioner’s opinion on sources of patient dissatisfaction with the ED

Category Responses Percentage (95% confidenceinterval)

Long waiting times 129 71 (65–78)Poor communication 11 6 (3–10)Poor staff attitude 8 4 (1–7)Doctor inexperience 4 2 (0–4)Unclear diagnosis 3 2 (0–3)Inadequate follow up 3 2 (0–3)Lack of food/comfort 3 2 (0–3)Elderly discharge at night 2 1 (0–3)Other 4 2 (0–4)No response 11 6 (3–10)

Total 181 100

From ED to GP


cares for the patient so the information relayed byphone is lost.’

Discussion

Although it has been suggested that discharge summa-ries from hospitals are not always adequate,9,14,15 wewere keen to explore this in our situation. It has beensuggested that communications from ED to GP shouldbe used as a performance indicator.15 We agree withpreviously published data that postal surveys allowGPs to provide information and comments informing usof the quality of care provided.3

A previous study noted only 60% of patient-deliveredED discharge letters reached the GP within 14 daysafter discharge.5 We found 86% of GP reported receiv-ing a letter within 14 days, a marked improvement overthis prior study and closer to the delivery rate noted forpatient-delivered inpatient discharge summaries in astudy 20 years ago.6

We speculated that GPs would prefer electronic com-munication such as email; however, this was not thecase, and surprisingly fax transmission was the secondmost popular choice behind the current patient deliverymethod. There remain, however, significant difficultieswith security and confidentiality of fax communica-tions to GPs. One group was able to demonstrate asuccessful programme of faxed information from an EDto GPs, but only involving 77 GP.7 Our study covered380 GPs and issues regarding maintenance of a data-base of up-to-date fax numbers to prevent informationmisdirection, and also consent to fax information to apatient’s usual GP and/or ‘out of hours’ GP need resolv-ing before this can be made standard practice. Only asmall minority of GP respondents suggested electronictransmission of the patient discharge summary,perhaps because of lack of technology infrastructure.

One evaluation of email communication links from EDto GP found that outcome measures of repeat visits toED or the use of pathology services were not affected.16

There are advantages to patient delivery of dischargeletters. This method may encourage the patient to seetheir GP allowing them to take control of their health-care management; the letter is available to whicheverdoctor first sees the patient after discharge; and mayact as a therapeutic tool as many patients will read theletter whether sealed or not.5

Good communication from ED to GP is likely topromote continuity of patient care and as an examplehas been shown previously to improve asthmaticpatient follow up by GP after ED attendance.17

Although we did not specifically ask about this topic,many GPs wanted to be informed when their patientswere admitted to the ward from ED. Also ‘out of hours’GPs were keen to hear the outcome of the patients theyreferred even if they were not the patient’s usual GP.

On the whole, GPs appeared satisfied with the ED’swritten communication, assessment and treatment ofpatients, and overall service to GPs and their patients.This may reflect a selection bias for positive responses,although previous research has found the conversemore likely to occur.13 A significant finding was thedifficulties GPs face in arranging outpatient appoint-ments for their patients and further investigations whenrequested. This might have impacted on their assess-ment of the service they receive from ED. The reasonthat GPs are often asked to arrange further manage-ment is to allow the patient to meet with their usualhealth-care provider to discuss the options for furthermanagement of their condition outside of the acutesetting, and to maintain ‘arms length’ referral patterns.Organizing referrals and outpatient appointments canbe difficult and time-consuming for GPs, and someagreed that although difficult it was part of their role,whereas others did not.

Table 4. General practitioner’s (GP’s) opinion on sources of patient satisfaction with the ED


Staff attitude (courtesy, empathy, caring) 33 21 (14–27)Quality of care 69 43 (35–51)Range and access of services 9 6 (2–9)Resuscitation and emergency treatment 10 6 (3–10)Communication to GP 1 1 (0–2)Triage quality 2 1 (0–3)No patient satisfaction 3 2 (0–4)No response 33 21 (14–27)

Total 160 100

N Lane and MJ Bragg


Feedback suggested GPs were not always aware ofavailable hospital outpatient services and one requestedus to publish a directory of emergency clinic services.

Another significant area of difficulty for GPs follow-ing patient discharge from ED was accessing outstand-ing results. This was mainly resulting from problemstelephoning the departments. Some GPs suggested theuse of direct links with the hospital pathology system aswell as faxing/posting results to them.

A number of the responses to the questions men-tioned illegible letters or lack of name of treating doctor.All our ED discharge letters are computerized and havebeen for over 5 years, and they automatically show thename and grade of the doctor writing the letter at thefoot of the page. Letters are only handwritten whenthere is computer failure. We surmised therefore thatthese comments might reflect GP confusion between EDdischarge letters and inpatient hospital discharge sum-maries, most of which are still handwritten. It is there-fore also possible that other responses in the surveyrelated to ward discharge summaries rather than the EDdischarge letter.

In our institution the ED admitting officer role isperformed by an emergency physician or emergencyregistrar. Recent increased senior staffing has helpedsupport this role. Calls from GPs are transferred to theED admitting officer via a dedicated cordless phone.Information received from the GP is recorded in theEmergency Department Information System, allowingthe doctor that subsequently assesses the patient toaccess this information. This method has been previ-ously recommended.10 In our survey GPs appeared tovalue the admitting officer as a contact person in ED;however, a substantial minority were still simplysending patients with a letter. This might be related tothe negative experiences with the system that some GPsreported. The idea of a phone call before sending thepatient to ED allows two-way communication regardingpatient referral, with potential for advice regardingalternatives for optimal management of the patient aswell as the resources available to the GP and ED. Lowrates of telephone referral by GPs have been notedbefore with only 8.3% using the phone in one study.10

In this survey 59% of GPs stated they telephonedwhen referring patients to ED either with or withoutan accompanying letter. Interestingly, some GPs wereunder the perception that the ED admitting officerwould be the doctor who assessed the patient once theyarrived in ED.

As is the case with most survey research, the resultsof the present study are limited by the response rate. It

is potentially possible that a majority of non-respondershad views contrary to the conclusions we have drawnfrom the data and with a response rate of only 39% thiscould invalidate our results. The low response rate maypartly be explained by the large catchment area wetargeted, as it is possible that more distant GPs mightgenerally refer to alternate metropolitan ED, andconsequently be disinclined to respond to this survey.Additionally, we limited our mail-out to members of oursurrounding GP Divisions, potentially missing up to20% of GPs in our area.

The results of the present study reflect the situationof a particular ED, and although some results might begeneralizable to other EDs, many of the issues might bespecific to this department and the referring GPs.

Conclusions

Good communication between GP and ED is importantin preventing adverse events and ensuring optimal con-tinuity of care. ED should develop systems to optimizedelivery of all discharge letters to GPs. In this survey justover half of GPs agreed with patient delivery of EDdischarge letters with a sizeable minority suggesting faxtransmission of summaries. Despite many GPs sup-porting the current system, there is a perception that asubstantial number of discharge letters do not reach theGP. Email delivery of discharge information is appar-ently not a priority to most GPs in this hospital area, andfurther research is needed to determine where benefitswould be gained. Although the majority of GPs rated ourcommunication with them as average or better, there areareas that have the potential for improvement. Dischargeletters require a clear management plan, as well as arecord of any medication update. Although most respon-dents found the admitting officer role useful, access tothe admitting officer was a reported problem, conse-quently this process has since been altered in our ED. GPconcerns regarding access to pathology and radiologyresults need to be addressed, as the current system isinefficient, ad hoc, and very time-consuming. Overall, weagree that a survey of local general practice is a usefulquality evaluation tool for ED.

Acknowledgements

The Sydney Eastern, Central and South-eastern Divi-sions of General Practice supported the present researchsurvey and provided address labels for the GP mail-out.

From ED to GP


We would like to gratefully acknowledge all the GPswho took the time to respond to the survey.

Competing interests

None declared.

Accepted 18 March 2007

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