To GP or not to GP: a natural experiment in children triaged to see a GP in a tertiary paediatric emergency department (ED).

Objective To evaluate the impact of integrating a general practitioner (GP) into a tertiary paediatric emergency department (ED) on admissions, waiting times and antibiotic prescriptions. Design Retrospective cohort study. Setting Alder Hey Children's NHS Foundation Trust, a tertiary paediatric hospital in Liverpool, UK. Participants From October 2014, a GP was colocated within the ED, from 14:00 to 22:00 hours, 7 days a week. Children triaged green on the Manchester Triage System without any comorbidities were classed as GP appropriate'. The natural experiment compared patients triaged as GP appropriate' and able to be seen by a GP between 14:00 and 22:00 hours (GP group) to patients triaged as GP appropriate' seen outside of the hours when a GP was available (ED group). Intention-to-treat (ITT) analysis was used to assess the main outcomes. Results 5223 patients were designated as GP appropriate'-18.2% of the total attendances to the ED over the study period. There were 2821 (54%) in the GP group and 2402 (46%) in the ED group. The median duration of stay in the ED was 94 min (IQR 63-141) for the GP group compared with 113 min (IQR 70-167) for the ED group (p<0.0005). Using the ITT analysis equivalent, we demonstrated that the GP group were less likely to: be admitted to hospital (2.2% vs 6.5%, OR 0.32, 95%CI 0.24 to 0.44), wait longer than 4hours (2.3% vs 5.1%, OR 0.45, 95%CI 0.33 to 0.61) or leave before being seen (3.1% vs 5.7%, OR 0.53, 95%CI 0.41 to 0.70), but more likely to receive antibiotics (26.1% vs 20.5%, OR 1.37, 95%CI 1.10 to 1.56). Sensitivity analyses yielded similar results. Conclusions Introducing a GP to a paediatric ED service can significantly reduce waiting times and admissions, but may lead to more antibiotic prescribing. This study demonstrates a novel, potentially more efficient ED care pathway in the current context of rising demand for children's emergency services.