Australasian Emergency Nursing Journal (2011) 14, 217—225

Available online at www.sciencedirect.com

journa l homepage: www.e lsev ier .com/ locate /aenj

SYSTEMATIC REVIEW

A systematic review of the impact of afterhours caremodels on emergency departments, ambulance andgeneral practice services

Margaret M. Fry, PhD ∗

Faculty of Nursing, Midwifery and Health University of Technology, Sydney 2007, Australia

Received 31 March 2011; received in revised form 16 September 2011; accepted 20 September 2011

KEYWORDSSystematic review;Afterhours care;Workforce;Emergency;Health care reform;Service delivery

SummaryIntroduction: The aim of the systematic review was to examine (i) the impact of afterhoursprimary care models on ED, ambulance services and or general practitioners and (ii) theeffectiveness of these services (afterhours) on nurse practitioners and/or the medical doctorsdelivery of care.Method: Articles were assessed using the Critical Appraisal Skills Programme (CASP) makingsense of evidence tools and covered the period from 1970 to 2011. The data sources searchedwere: Cumulative Index to Nursing and Allied Health literature, Medline, EMBASE, The CochraneDatabase of Systematic Reviews, PubMed, Science Direct and Proquest.Results: A total of 2268 were retrieved and 419 studies were identified. Eighty-seven studieswere found to be relevant. Nine countries are represented in the data. There were few rele-vant Randomised Controlled Trials (n = 5). The evidence was largely based on quasi experimental(time series), before and after or comparative studies. Studies were usually set within a sin-gle hospital or community setting with heterogeneous samples, short sample periods, and ormeasured a single outcome such as patient satisfaction.Conclusions: Six models were identified from the review which highlighted evidence that after-

hour care models can reduce GP workload and to a lesser extent ED and ambulance services.Potentially these models could ease acute care work load, improve access across the vastgeographical distances of Australia.© 2011 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

∗ Corresponding author. Tel.: +61 02 9514 4826;fax: +61 02 9514 4835.

E-mail address: margaret.fry@uts.edu.au

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1574-6267/$ — see front matter © 2011 College of Emergency Nursing Audoi:10.1016/j.aenj.2011.09.001

ntroduction

ustralian acute care health services are facing a signifi-ant burden. Specifically, emergency departments (ED) havexperienced change in patient volume, demographics, com-lexity, ambulance transports, referral patterns and patient

stralasia Ltd. Published by Elsevier Ltd. All rights reserved.

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Table 1 Medical Subject Headings (MeSH) and unrestrictedterms used retrieve abstracts.

MeSH terms Unrestricted terms

Emergencies Emergency departmentEmergency outpatientsEmergency nursingTelephone hotlinesEmergency treatmentNurse practitionersMinor injuries unitsEmergency service

Primary health care Continuity of patient carePatient centred careRefusal to treatProgressive patient careAfterhours careManaged care programsDelegation, professionalHealth care reformHealth services accessibilityOutpatient clinicsNight careTelephonePrimary health careTelephone adviceWalk in CentreAmbulanceOut of hours and afterhourscare and health centres

Primary care nursing Emergency nursingHome nursingCommunity nursingNursing, practical

Community health services Community health servicescommunity Health nursingCommunityEmergency medical servicesAmbulatory care facilitiesNon hospital health careservicesPrimary health careRemote consultations triage

General practitioner (GP) AdultPatient care teamsRural healthUrban healthHouse callsGP afterhours care

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18

xpectations.1 There is also a growing trend for patient’s toypass their general practitioner (GP) and as a workforcehey are reducing their work hours.1 Given these factors its not surprising that the annual Australian ED presentationate continues to increase above population growth withresentation rates rising 4.9% annually.2 If Australia is toave a sustainable healthcare system and improve patientutcomes we need to look more closely at innovative after-ours care models that will meet staff and public need.

Internationally, there has been a general decline,ver the last two decades, in afterhours primary health-are services.3 The response has led to increasedse of acute services. The increased acute serviceork load has led to significant primary healthcare

eforms.4—6 Primary healthcare reforms were achievedhrough the implementation of new and innovative careodels.The aim of the systematic review was to examine the (i)

mpact of afterhours primary care models on ED, ambulanceervices and or general practitioners and (ii) effectivenessf these services (afterhours) on nurse practitioners and/orhe medical doctors delivery of care.

eview search strategy

he search covered the period from 1970 to 2011. No dater language restrictions were initially applied. Afterhoursas defined as a consultation conducted on a public hol-

day, Saturday and or Sunday or any time on a weekdayetween 6 pm and 8 am. A restricted search was under-aken for Systematic Reviews and Randomised Controlledrials (RCT). An unrestricted combination of Medical Subjecteadings were searched and combined with unrestrictederms (Table 1). A total of 2268 articles were reviewedy abstract and title. From the 2268 articles, 419 stud-es were retrieved, identified and examined. The authoread all articles. Eighty-seven studies were assessed usinghe Critical Appraisal Skills Programme (CASP) making sensef evidence tools (Figure 1). Inclusion criteria included:fterhours care models that provided outcome measuresdescriptive or statistical) that examined impact on EDs,mbulance services, primary care and GPs. Editorials, inter-iews, opinion pieces and letters were excluded from theeview.

atabases accessed

he following databases were searched: Cumulative Index toursing and Allied Health literature, Medline, EMBASE, Theochrane Database of Systematic Reviews, PubMed Science,irect and Proquest. The review was supplemented with aanual search of the relevant grey literature.

esults

ighty-seven studies were found to be relevant. The

ajority of studies vary in settings and methodology (het-

rogeneous samples, short sample periods, descriptive inature; conducted within a single site; lacked statisticalower and or measured a single primary outcome such as

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GP Co-Operatives

atient satisfaction) (n = 82). There were five RCTs. Thevidence was largely based on quasi experimental (timeeries), before and after or comparative studies (n = 24).he relevant literature was largely international (83%), soesults need to be interpreted cautiously, given Australia’s

eographical, cultural and social differences. Articles repre-ented the United Kingdom (n = 44), Australia (n = 15), Unitedtates (n = 7), Netherlands (n = 7), Denmark (n = 5), Swedenn = 4), Canada (n = 2), Ireland (n = 2), and Scotland (n = 1).

Review of impact of afterhours care models 219

Full text obtained for examination (n = 419)

Studies excluded based on evaluation of the

abstract (n = 1849)

• Description, discussion, opinion (n = 1089)

• Planned model implementation (n = 26)

• No workload impact discussed (n = 102)

• Focus was cost analysis (n = 24)

• Focus was on NP practice/role (n = 604)

Studies excluded after review of full text (n =332)

No after hours workload identified (n = 218)

Focus not on impact (n = 114)

Studies included in review (n = 87)

after application of CASP tools

Relevant studies identified by

title and abstract (n = 419)

Potentially relevant studies identified

by electronic search (n = 2268) Databases accessed

Cumulative Index to Nursing and

Allied Health literature (n=318)

Medline (n=988)

EMBASE(n=31)

The Cochrane Database (n=5)

PubMed (n=35)

Science Direct (n=684)

Proquest (n=207)

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Study results often noted an impact on acute services butfailed to detail or provide the statistical difference. Thereview identified six afterhours care models that had ademonstrated impact on EDs, ambulance and or generalpractitioners.

Model 1: Minor Injury Units (MIUs)

Minor Injury Units (MIUs), while not specific to afterhourscare (0700—2200 h; seven days) had been implemented inthe UK,5,7—9 Canada10,11 and USA.12 MIUs were established ina variety of settings but mainly within or nearby an ED, orco-located within a Primary Care Health Centre (PCHC). Inthe UK these units were implemented as either nurse led, GP

led or in collaboration with ED physicians.5,7—9 Within the EDsetting patients choose or were triaged to the MIU. Unlikethe UK model, the USA and Canadian MIU were primarily GPled.12 Much of the evidence involved one site and focused

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selection process.

n comparing nurse practitioners (NPs) with ED medicaltaff in the management of patients with minor injuries orllness.13

A UK study9 identified ED activity reduced by 24%ithin three months of the MIU opening and that 20,000atients attended at an average cost per patient of UK£33.aiting times were low and 67% of patients were dis-

harged. It was generally accepted that a percentagef these patients would previously have had sought EDare.

A multicentre RCT14 examined practice nurses, workingn a GP clinic, managing minor illnesses. The model aimed toeduce the impact on GP workload. The nurse consultationsn average were 2 min longer than medical consultations.

atients were slightly more satisfied with nurse consulta-ions than with doctors (mean (SD) score of satisfaction 78.616. 0) of 100 points for nurses versus 76.4 (17.8); CI 95%or difference between means −4.07 to −0.38). Nurses and

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octors provided a similar proportion of patient pre-criptions (nurses 481/736 (65.4%) versus doctors 518/81663.5%)). Nurses managed 73% of patients (577/790) withoutny input from doctors. The study provided evidence thatinor injury and illness patient groups could be redirected

rom acute services and GPs to be managed by nurses.Similar studies15,16 conducted at a London Hospital found

hat the MIU had exceeded expectations with a significanteduction in patient waiting times, greater standardisationf practice, improved patient satisfaction, increased healthromotion screening, improved communication and moreppropriate primary care referrals. However, no statisticalvidence was provided. A RCT7 which assigned 1453 minornjury patients to either a NP or junior doctor and found thatPs were better equipped than junior doctors at record-

ng medical history and fewer NP patients had unplannedollow-up with no significant differences in the accuracy ofxamination, adequacy of treatment, requests for radiog-aphy, interpretation of radiographs, or planned follow-up.he study demonstrated the safety of NP MIU managedatients, although the reduction in ED workload was notpecified.

odel 2: Walk in Centres (WiCs)

alk in Centres (WiCs) are, drop in, nurse led models andsually opened between 0800 and 2200 h (seven days). Inanada WiCs were accessed by patients more often after-ours than in business hours.17 In the UK WiCs were locatedn shopping centres, nearby EDs or in PCHC. In the UKwo million people had utilised WiCs within two years ofmplementation.18 Similarly in the USA 3800 WiC had beenstablished by late 1980s and in seven years, 53 millioneople had been treated and managed.19 In Canada similarresentation rates were evident.12,17,20 The first AustralianiC opened in 2010.21

In the UK a two year before and after study,22 using aarge sample (10 WiCs; 20 EDs; 40 GP clinics). The findingseported, although not statistically significant, a decreasen ED (−175) (CI 95% −387 to 36) consultations per depart-ent per month and GP (−19.8) (CI 95% −53.3 to 13.8)

onsultations per 1000 patients per month.A patient survey study23 was conducted and compared

8 UK WiCs and 34 GP clinics. The key reasons given forttendance were speed of access and convenience. WiCsers were more likely to be on the first day of illness (28%ersus 10%; P < 0.001), did not expect a prescription (38%ersus 70%, P < 0.001), and continuity of care was less ofconcern (adjusted odds ratio = 0.58; 95% CI = 0.50—0.68).

t is reasonable to consider that this population group mayave previously used ED or GP services. Similarly, a Cana-ian study17 found 83% of users would have sought medicalttention at an ED, another WiC, or from their regular GPf opened. In the UK, the extended hours non-appointmentystem of WiCs, along with family GP reluctance to workvenings and weekends, made these clinics an attractive

ption for the public.18,24

In the UK while high patient satisfaction levels withiCs persist the demand on other acute services had not

ecreased.25,26 However, in a later study22 66% of WiC

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M.M. Fry

atients confirmed that they would have attended an EDf the centre was not available.

odel 3: Telephone triage and advice centres

elephone triage advice centres were established nation-lly and internationally with the aim of diverting afterhoursrimary healthcare users away from EDs and GPs.27 Interna-ionally, telephone advice services usually operated 24 h andere often integrated with other PCHC. There was strongvidence in the UK that telephone triage advice centreseduced afterhours PCHC presenters and telephone calls toDs, GPs and to a lesser degree ambulance service.28—30

ational telephone triage advice call centres were imple-ented across the UK (nurse led),31 Denmark (GP led)32,33

nd the Netherlands (GP led)34 and more recently AustraliaGP led).35

‘NHS Direct’ was the UK national telephone advice callentre.30,36 Since implementation in 1999, ‘NHS Direct’ctivity had increased by 4 million callers. One reportemonstrated a reduction in GP cooperative utilisation butot with ED services.29 Analysis of patient management sug-ested that many had been diverted from attending an ED,fterhours or GP services, which they may have otherwiseought. There was no doubt that a proportion of these callersould have utilised other acute services.4,31,37

Early studies38—41 suggest that telephone advice centresould reduce ED activity up to two thirds and GP work-oad by 50%. A 12 month RCT in the UK42 identified 14,492alls were received (7308 in the control arm; 7184 in thentervention arm). Nurses managed 49.8% of callers withouteferral. The impact was significant with a 69% reduc-ion in GP telephone advice calls. Another similar studyndertaken in 200543 quantified the service integration offterhours care through ‘NHS Direct’. The study found aignificant but small down turn in demand for care in twoP cooperatives. Integration of the call management modelas achieved and 29% achieved single call access for allatients.

A number of reasons are cited for the effectivenessf telephone triage and advice services for reducing EDorkload. Within the international context of healthcare

eform there was already widespread acceptance of nursesroviding autonomous, safe, competent, and often moreimely care for a range of patient conditions.3,27 In theK the national telephone triage advice call centre was

mplemented with medical staff engagement, in the devel-pment of protocols and triage programs, and believed toave sustained the success.44 The telephone advice centrerovided a first contact option for callers. Incentives forallers were built into the service with the additional pro-ision of screening, health information, secondary urgencyriage and a residential care on line care services. Telephoneriage advice centres enabled quicker access to health infor-ation and advice reducing the need to attend an ED orP.34,39,41,42

NHS Direct began as a UK telephone triage service,

lthough was later extended to include the Internet asn alternative service strategy. Web user demand hasncreased from 1.7 million to 3.5 million in March 2008.36

tudies30,31,36 are demonstrating good patient satisfaction.

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Review of impact of afterhours care models

Generally triage advice centres have enabled quicker accessto health information and reduced the need to attend anED.34,39,41,42

A study34 examined telephone triage nursing practices.The cross-sectional, multicentre, observational study foundthat nurses correctly estimated urgency in 69% of calls andunderestimated urgency in 19% of calls. The sensitivity andspecificity was found to be 0.76 and 0.95, respectively.The positive and negative predictive values of the urgencyestimates were 0.83 and 0.93, respectively. No adverse out-comes or impact on acute services were reported.

In the Netherlands GP coordinated telephone advice cen-tres were being recommended.34 Additional doctors at thecentre provided a home visit service.45 A five year compar-ative before and after study in Denmark33 examined theimpact on afterhours care. The telephone advice modelhad nearly doubled GP telephone consultations (48%), whilehome visits reduced by 18%. Others45,46 identified a declinein ED activity (particularly frequent ED attenders) attributedto the implementation of the GP telephone consultationsservice. In contrast, one study32 noted a smaller reductionon GP workload but found no statistical impact on ED orambulance services.

Throughout Australia there has been various telephoneadvice call centres established ‘Kidsnet’ (1997), ‘HealthDi-rect’ (1999) and ‘HealthConnect’ (2000). Kidsnet identifiedmost callers were reassured and were referred to a GP.47

Evaluation of HealthConnect48 found that about 50% ofcallers were managed without ED or GP referral. In AustraliaHealthDirect became part of the National Health Call Cen-tre Network (NHCCN), a nationwide system operating from asingle telephone number.49,50 A recent review identified theservice had reduced ED activity by 15.5%.49

In the UK telephone triage advice services were com-monly located in PCHC and which usually comprised of a WiCand or deputising GP services (locum). Two UK studies51,52

found that higher attendance rates occurred when PCHCswere co-located near EDs and therefore had greater impacton reducing ED activity.

A USA study53 identified that PCHC with a high proportionof primary care physicians was associated with significantdecrease in acute care service utilisation. An annual 1%increase in primary care physicians was associated with adecrease of 503 hospital admissions, 2968 ED presentations,and 512 operations (all P < 03).

Model 4: GP Co-operatives services

Nationally and internationally there has been a decline inGP afterhours care largely driven by work force, social andlife style issues.1,3 Within the UK,29,54 Denmark,32,55 andSweden56—58 GP cooperatives had replaced the solo GP clinicin response to declining afterhours services. InternationalGP Co-Operatives could have a few or hundreds of GPs, andinclude a telephone triage advice service, provide home vis-its and were often located near an ED. Similarly in Australia,but to a lesser extent, has been the implementation of ‘Divi-

sions of General Practice’.59,60

GP Co-Operatives generally improved afterhours servicedelivery and reduced ED referrals and GP work load.61,62

Two UK studies63,64 identified reduced GP home visits; lower

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rescription rates; and higher telephone advice and refer-als to PCHCs and hospitals compared with deputised locumedical services.A cross-sectional study in the Netherlands65 of four GP Co-

peratives identified the average home visit waiting time for827 patients was 30.5 min. The evidence suggested trafficntensity, home visit intensity, and urgency influenced homeisit waiting times. Of concern was that patients with a life-hreatening complaint (and minimal coordinated ambulanceervices) experienced an increased waiting time the furtherhe patient’s home was from the Co-Operative.

A number of Swedish studies56,57,66 demonstrated a signif-cant increase in primary healthcare usage with telephoneonsultations rather than GP home visits and was associatedith a 53% reduction in ED workload. In these model GPs

eported high levels of satisfaction.In Ireland a survey67 of 221 GPs, in mixed urban and rural

o-Operatives, was conducted. A response rate of 82% con-rmed that the Co-Operative model had a positive effectn their lives. The majority (63%) would prefer a GP/Healthoard partnership for the organization of afterhours care.Ps perceived the service would be enhanced with greaterursing, mental health, dentistry, pharmacy and social worknvolvement.

In Australia, afterhours GP Co-Operative trials were con-ucted in New South Wales (NSW),59,68,69 Western Australia,3

ictoria,70,71 and Tasmania.72 In NSW an afterhour GP clinicemonstrated a reduction in ED Triage Code Category 4nd 5 patients.59 Another study73 measured the impact ofGP clinic (solo GPs) co-located near an ED. The study onlyoted a trend and failed to achieve statistical evidence. Thevidence of impact on acute services was not statisticallyignificant, acceptance by local GPs varied and no financialavings were identified. More recently, an ED reduction of.04 patients daily (95% CI 5.39—8.70), with a total presenta-ion reduction of 8.2% (95% CI 6.2—10.2) was identified withhe opening of a co-located after-hours clinic.69 Australianvidence was mixed.3,68,74

odel 5: Ambulance officer managed care

n the UK increased ambulance utilisation was identified withhe implementation of ‘NHS Direct’, this was due to delayn service provision rather than as a consequence of theervice.43 From a sample of 34 GP Co-Operatives there werenly three (one control; two intervention) sites that experi-nced an increase in ambulance usage (5%, −0.02% to 10%,= 0.06; 6%, 1—12%, P = 0.02; 7%, 3—12%, P = 0.001). Thereas no evidence to determine if the cases transferred wereppropriate or inappropriate. The increase in acute serviceorkload and ambulance transfers has led to the introduc-

ion of extended practice roles for ambulance officers.In the UK, a paramedic ‘‘see and treat’’ protocol75 for

he management of minor injury or illness to reduce EDorkload was implemented. The cluster RCT trial involved6 urban ambulance stations. The sample included 3018

atients (>60 years) who called an ambulance (n = 1549ntervention, n = 1469 control). Paramedic treated patientsere less likely to be transported to an ED (relative risk 0.72,5% CI 0.68—0.75) or need hospital admission within 28 days

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0.87, 0.81—0.94). The model had a positive impact on EDsnd ambulance officers reported high levels of satisfaction.

A study76 implemented and evaluated a ‘treat and refer’mbulance protocol. The evaluation identified that thereas no difference (93/251 (37.1%) versus 195/537 (36.3%),= 0.90, 95% CI of difference −6 to 7) in the proportionf patients left at the scene in the intervention or con-rol group. However, the job time was longer 8 min forhe ‘treat and refer’ group than the intervention group35 min versus 27 min, P < 0.0001, 95% CI of differences—11). Three patients in each group were left at homeut subsequently admitted to hospital within 14 days. The‘treat and refer’’ protocol was used appropriately but someafety issues were identified. Authors suggested that refine-ent of protocols, decision support systems and further

raining would achieve a greater impact on other healthgencies.

A 12 month study77 implemented and evaluated a ‘MIUeferral’ protocol to reduce ED activity. Ambulance crewsould directly refer to a MIU on randomly selected weeks.he sample identified 41 intervention patients groupsttended an MIU, 303 attended an ED and 65 patients wereot transported. The control randomised cluster group com-osed 37 attended the MIU, 327 attended ED and 61 wereot transported. Ambulance service job time was shorter forIU patients (−7.8, 95% CI −11.5 to −4.1); compared withDs (−222.7, 95% CI −331.9 to −123.5). The MIU patientsere 7.2 times as likely to rate care as excellent (95% CI.99—25.8). The evidence suggested that ambulance crewsould make appropriate referrals to MIUs and reduce EDctivity.

In Denmark, nearly 50% of EDs were closed and replacedy ambulance cars staffed with a doctor.78 The new modelas ‘to bring the hospital to the patient’. The evidenceas insufficient to determine if ED activity was reduced ormbulance care could replace an ED visit.

In contrast, a Swedish study79 identified a 24% reduc-ion in ambulance transfers with the implementation of a4 h PCHC co-located within a city ED. The before and aftertudy, identified a significant reduction in ED presentationsnd ambulance transfers, although not specified. The studyid not differentiate afterhours operation and so the impactould not be determined.

odel 6: GP service integrated within emergencyepartment team

here were significant positive findings with the employ-ent of GPs in EDs. This integrated service provided for

reater continuity of care and appealed to primary carehysicians. The evidence of impact of GPs providing a pri-ary care service within ED traced back to the late 1970s

nd varied considerably. Studies in the UK,80 Sweden79 andSA81 demonstrated ED workload was reduced with GPs by4%, 40% and 27%, respectively.

A RCT82 was conducted of a primary care service locatedn a paediatric ED. The doctor led model reduced the ED

epresentation rate by 50%. However, the service was 24 hnd so the afterhour impact could not be determined. OtherK studies83,84 demonstrated ED based GPs reduced investi-ation, referral, and radiology rates and cost significantly.

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M.M. Fry

Ps also managed 16.8% of the non-urgent ED presenta-ions. Similar findings were identified in Ireland85 and theSA.53

A number of ED based afterhours GP clinics werepened in NSW Australia to provide a primary healthcareervice.73,68,86 The evidence suggested that a proportion ofhese patients were likely to use other acute services.

iscussion

he review identified that much of the evidence lacked aigorous design and or statistical evidence. Studies ofteneported a positive impact on health care services but failedo show a statistical difference. The majority of the litera-ure was from the UK. Given most of literature reviewed wasnternational results may need to be interpreted cautiouslynd further research required.

In the UK, NP led MIUs are managing up to 90% of patientsithout referral to an ED.9,87 The UK MIUs provided timely,

ree, non appointment and afterhours option. If MIU patientsre managed appropriately, and with minimal investigativeuplication by a GP or ED and referral then the impact isikely to be a significant reduction in ED activity.8,88 Thereas evidence that MIUs, NP or GP led, redirected patientsroups that would have used ED or GP services. Applicationf this model for the Australian context warrants furthernvestigation.

There was weak evidence to suggest that WiCs couldeduce ED activity afterhours by managing patients withinor injuries and illnesses. WiCs appeared to satisfy a pri-ary healthcare need, although limited research preventeduantifying the afterhour’s impact.4,89,90 WiC utilisationppeared based on the convenient location, free service,fterhours accessibility and timely non-appointment ser-ice delivery.90 While there has been some suggestion thatatrons may use these services for a second opinion the evi-ence was inconclusive. In addition, it is unclear whethersecond opinion may still have been sought from other

ealth agencies such as a GP or ED.26 The evidence istatistically weak and further research is required to exam-ne the impact of WiCs on ED presentation rates and GPorkload.22,91

The impact of telephone triage on EDs and or GP workloadppeared significant. Specifically if centres had a one con-act number system, were free, well advertised, deliveredimely service and were nationally coordinated. Centralisedelephone services across large geographical areas appear toeduce demand on acute care services.4 Telephone adviceodels would appear to satisfy a particular primary care

roup who may well have utilised ED or GP services. Thisodel is supported with Australian evidence.49

GP Co-Operative services would appear to contributeowards a more positive impact on ED and GP services. Thereas evidence of PCHC and GP Co-Operatives reducing EDemand, hospital admissions, costs and GP workload. Theevelopment of collaborative multipurpose models is impor-ant, although higher presentation rates were associated

ith GP Co-Operatives and PCHC located beside or nearbyn ED.51,52

In NSW Australia ambulance activity has risen by 10%nd primary healthcare patients represent a portion of this

Review of impact of afterhours care models

group.1 There is also good evidence that ED overcrowd-ing delays ambulance services.92—94 However, the impact ofambulance treatment and referral protocols on ED and GPservices was limited. While the extended paramedic rolefindings were inconclusive the ‘see and treat’ and ‘treatand refer’ treated patients would have otherwise beentransported to an ED. Expanding the role of the Australianparamedic role would appear to warrant further research.95

Extended ambulance paramedic ‘see and treat’ and ‘treatand refer’ protocols have the potential to reduce ED activityand improve public access.

While the evidence of GP integrated ED services inter-nationally was convincing the Australian evidence is weakand requires further investigation. A collaborative andintegrative relationship between emergency staff, generalpractitioners, ambulance, NPs and other primary health careclinicians would strategically enhance care delivery.

The review identified six models which could help reformthe delivery of primary health care services within Australia.The application of these models within Australia is likely torequire cultural, social, legal and health care agency rolereform.

Limitations

Identification of studies was done by one reviewer and selec-tion bias may need to be considered. The criteria requiredidentification of a model of care and while six models wereidentified these may not represent all afterhour care mod-els.

Conclusion

The systematic review highlighted evidence that afterhourcare models can reduce GP workload and to a lesser extentED and ambulance services. MIUs, WiCs, telephone triageadvice centres, GP Co-Operatives, extended ambulanceroles and or GP integrated EDs may assist to ease acute careactivity, improve access and service delivery across the vastgeographical distances of Australia.

Provenance and conflict of interest

This paper was not commissioned and there are no conflictsof interest to declare.

Funding

No funding.

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