I’ve found myself becoming increasing concerned about the model of care being offered in many Accident and Emergency departments both in the UK and around the world. The below anecdote is a case in point for why I feel inappropriate ED attendances are dangerous for patients and the practitioners who try to manage them.
Recently a patient attended a local minor injuries unit with a diabetic ulcer on his toe. The ulcer was treated by the the practitioner who saw him, but later in the sequelae of the illness the patient required lower leg amputation due to an infection. Upon reflection of this, the department management decided that all future diabetic problems must to be referred to the diabetic outpatient clinic. While there may seem to be some logic to this reasoning, it is completely wrong, and I believe this overall model of care is dangerous to patients.
Although it would appear on the surface to be reasonable care, it is important to realise this was an inappropriate attendance to the Accident and Emergency Department, a diabetic toe ulcer is neither an accident, nor an emergency. This is not elitism, these presentations simply do not fall within the scope of work of the A&E department. Secondly the practitioner should not be attempting to manage these problems, whether an Emergency Nurse Practitioner or a Doctor, as this is not within their expertise or A&E training.
There appears to be a misguided mindset among some practitioners, that although these patients should not have attended ED, we should manage them if they do. This is both wrong and unsafe. By attempting to manage these patients we are working out of our scope of practice and competency; we have not been adequately trained to deal with these issues, and any management by the department will likely be suboptimal. Unlike a General Practitioner we do not have access to tools such as time and follow up; we have incomplete access to the salient GP records, and we have no knowledge of what stage the GP is with his/her existing management. Referrals to secondary care clinics by ED staff are often antagonistic and disrespectful to existing GP management plans, and are a constant frustration to good GPs.
The correct management should be ‘not to manage these patients at all’. If it is not an immediate emergency or an injury requiring first aid these patients should be referred to the appropriate doctor for care; the GP, who is better trained for these presentations, is better placed to give appropriate care, and is the ‘primary’ doctor for all non emergency patients.
Although it is tempting to manage the increasing inappropriate attendances to A&E, when we do we are taking risks by working out of our scope of practice and competency. We wouldn’t expect an ophthalmologist to pull a wrist fracture, and we shouldn’t be attempting to do general practice, it’s not as simple as we sometimes think. What would happen if the next sore throat you treated with a gargle turned out to be a missed throat cancer? Will you then send all future sore throats to ENT?
In my opinion, the safest course of action is to refuse to manage general practice presentations after assessment of whether an emergency is occurring (we are trained to do this). This is both in the medical interests of the patient, and the legal interests of the practitioner.
Practicing out of your scope of practice brings in issues of competency that could injure both you and your patient.