Table 3.

Factors That Influenced Gp Decision-Making When Referring Paediatric Patients To The Ed

PATIENT-LEVEL FACTORS
Parental Anxiety and perception of illness	•Parental anxiety had an influence on decision to refer [25, 29]. •Parental perceptions of the severity of illness may influence the decision [26, 29]. •GP’s trusted parents’ instincts and judgements of severity rather than take a risk on the child’s health, especially if they were unable to see the child. Referrals were more likely if parents stated the child was inconsolable or in severe pain, even when parents had not tried medication [26].
Parental pressure to refer	•GPs reported parent pressure for referral in order to avoid incurring cost, leading to what doctors reported as a “moral conflict” between offering good service to patients and adherence to best medical guidelines [25]. •15.8% of referrals in one study were due to a parent request [27].
Parental Capability	•GPs considered the parent’s health literacy, in order to judge their ability to understand, follow instructions and capability to adequately provide care and recognise a worsening condition. This was especially important when the patient was unfamiliar to them [25].
Child’s age & medical history	•GPs were more likely to approve a referral to the ED for younger patients especially those under two years old and for presentations of fever or trauma [30]. •GPs considered the child’s previous admission history when making a decision [26].
Socio-Economic Status	•GPs referred those of lower socio-economic status more frequently [25, 29]. •In one study GPs reported their perception of socio-economic status was based on place of residence, language and distance from medical centre [25].
GP-LEVEL FACTORS
Risk aversion	•GPs reported they often err on the side of caution by referring rather than risk a child’s health [26, 29]. •GPs stated they referred to their gut instinct, intuition and rule of thumb protocols when diagnosing patients [25, 29]. •A small number of GPs stated a lack of paediatric training would impact on their confidence [29]. •The legal implications and fear of lawsuits was reported as an influence on their decision to refer or not [25]. •On the other hand, GPs temporarily employed in the ED who carried out primary care consultations were less likely to utilize investigative and specialist resources, including radiography, prescriptions of antibiotics and referrals to specialist and outpatient clinics [28].
Preference for Referral destination	•In one study featuring both paediatricians and general family practitioners, paediatricians were more likely to refer to paediatric urgent care centres, while general family practitioners were happy to refer to any urgent care services [26].
SYSTEM-LEVEL FACTORS
Time of Day & Distance from ED	•GPs in one study were more likely to refer later in the day than in the morning [29] while in another GPs gave approval for ED visits for different reasons before and after 3.30 pm [30]. Visits were most commonly approved for being clinically urgent before 3.30 pm and after 3.30 pm a full office schedule was the most common reason cited [30]. Denial of a visit to the ED was more likely earlier in the day; 24/40 denials occurred before noon while 56/151 of approvals occurred before noon [30]. •Doctor’s reported referring more often on weekends (Friday-Saturday in Israel) especially Fridays [25]. •Patients accessibility and opening hours of medical centres were a consideration for GPs, and those living in isolated areas were referred to the ED more frequently [25].
Access to resources and diagnostics unavailable in primary care settings	•Lack of funds to continue treatment (17.1%), lack of facilities (14.5%) and lack of expertise (10.4%) were all reported as reasons for referrals [27]. •Patients were referred in order to access resources such as tests and treatments unavailable in primary care offices. Immediate referral was given for perceived need of sutures, laboratories, and nosebleed cauterization [26]. •The ED was used as a “middle man” in order to ensure publicly insured patients get access to outpatient specialty care and GPs refer them to the ED to facilitate their access to specialists [31].