Patients attending an emergency department with a general practitioner referral letter who are discharged home have a longer length of stay than those without a letter

Dear Editor, Efficient and accurate clinical handovers between ED physicians and general practitioners (GPs) are important to ensure the safe and timely continuation of patient care. We conducted a study to assess whether a patient presenting with a written GP referral and who is also discharged home had a longer length of stay (LOS) in the ED compared to patients without a written referral. Based on anecdotal experience, it was hypothesised that patients presenting with a written GP referral would have a shorter LOS, as a good referral letter would facilitate quicker patient processing and fewer repeated investigations. This study was conducted over an 8 week period (6 August to 1 October 2015) in the ED of Royal Prince Alfred Hospital, Sydney. This ED has an annual caseload of approximately 70000 adult and paediatric presentations, with a referral base of approximately 700 GPs. The study was prospectively designed but also included a retrospective chart review. Patients who presented on Sundays were excluded as Sundays are considered to be outside of standard GP working hours. We found that of the 4215 patients discharged from the ED, 310 (7.4%) had a written GP referral. Patients presenting with a GP referral letter (214.7 min, 95% confidence interval [CI] 203.7–225.7 min) were more likely to have a longer LOS than those presenting without a GP letter (201.7 min, 95% CI 198.2– 205.2 min), P= 0.03. Furthermore, referral letter content was important as 235 (75.2%) of the letters contained six or more of the nine key data fields (Fig. 1). These are the same data fields as used in Nash et al. Patients with more comprehensive referrals were found to have a longer LOS, with a mean of 220.4 min (95% CI 207.9–232.9 min) compared to 193.6 min (95% CI 170.1–217.0 min), P=0.047. This study is the first to demonstrate that patients who present to and are discharged from the ED with a GP referral letter are more likely to have a longer LOS than those presenting without a GP letter. Previous studies have confirmed that GPs make appropriate referrals to the ED. However, given resource limitations, they are at times unable to facilitate the complete work-up of a patient in the community and may also be unable to implement more complex management plans. We found that the majority of patients with a GP referral presented during business hours and only a small proportion of patients presented after 17.00 hours. This suggests that GPs may not have been referring patients to the ED simply because they did not have timely access to outpatient pathology and imaging services. Interestingly, we also found that over 30% of GP referrals were for paediatric patients who tend to be less complex and often have a single system disease. Age alone cannot determine patient complexity; however, this may be useful to determine if LOS in this cohort is a good marker of complexity. Unfortunately, we were unable to perform further data analysis. Further study is required to understand the significance of LOS as we acknowledge that there are many confounding factors. These include a lack of access to previous patient records and results, ED management of patients with unrealistic expectations and system-based factors such as bed availability. We have attempted to limit these influences by including only patients discharged from the ED. Further study is also required to understand the relationship between patient complexity and LOS and to identify which aspects of GP referral letters contribute positively to the patient’s journey in the ED.