Why more patients are ending up in emergency departments

Referrals to EDs are rising and the causes must be addressed

The waiting room is not what it used to be. Much has changed in general practice. Patients are coming in earlier, later, sicker, or with stranger symptoms, and sometimes all of these things happen at the same time. The familiar patterns of the past, like the usual coughs and colds, urinary tract infections, and childhood fevers, are still there, but they’ve been pushed aside by more complicated and uncertain cases. It’s like the old rhythms of general practice have been disrupted by a new, more complex beat. Doctors have to be ready for anything and they have to be able to handle cases that are more layered and more challenging than ever before.

What has changed?

Start with multimorbidity. It’s everywhere. The neat, single-diagnosis patient has become the exception rather than the rule. A patient with breathlessness isn’t just breathless. They have chronic obstructive pulmonary disease, heart failure, diabetes, mild cognitive impairment, and a medication list that reads like a small formulary. Each condition interacts. Each drug muddies the water. Each symptom becomes harder to interpret.

When you add frailty to the mix, things get even more complicated. It’s not just about how old someone is, but also about their physical vulnerability. A small infection can quickly turn into a big problem, like delirium. And if they fall, it’s not always just a simple ‘mechanical’ issue – it may well be a manifestation of an under-ying metabolic, neurological, endocrine, or cardiovascular problem. Balanced clinical judgement is critical, because the room for error gets smaller and smaller. If you make a mistake, the consequences can be significant.

Time is a big issue here. Increasingly, doctors, both in general practice and in hospitals, have very little of it. We often only have 10 minutes, or sometimes even less, for each patient. And the real issue now is, who can be managed in the community and who needs onwards acute/emergency referral? It sounds simple. It isn’t.

Chest pain used to be more straight- forward, but nowadays, it’s not so clear-cut. We’re seeing more atypical cases, especially in younger patients who have risk factors, and older patients who have vague symptoms. Sometimes the ECG comes back normal, but that doesn’t necessarily mean everything is okay. And to make matters worse, troponin tests aren’t always available in community settings. So, the GP is left with incomplete information, trying to make a tough decision. Is it safe to manage this patient’s care here, or is this the start of something that could quickly spiral out of control?

Think about sepsis for a moment. The message has gotten across, but maybe it’s had too much of an impact. A patient might have a fever, a high heart rate, and is breathing faster than usual. But when the patient is seen in community settings, these symptoms can be easy to overlook because they’re so common in everyday illnesses. The thing is, viral infections can look a lot like bacterial infections, making it tough to tell them apart. And then there are the elderly patients, who might not even develop a fever. Children, on the other hand, can seem fine until suddenly they’re not. As a result, doctors are more likely to refer patients for further evaluation, which is understandable – no one wants to miss a case that could be serious or life-threatening.

Mental health is a big concern. We’re seeing more patients with mental health issues and their cases are getting more complicated and severe. When it comes to assessing the risk of harm to themselves or others, it’s not just about ticking boxes on a checklist. It’s about having a real conversation with the patient, understanding their situation, and using our judgment to make a decision. We need to figure out if the patient needs to see a psychiatrist that day, or if it’s safe to let them go home. We also need to think about what kind of support system they have in place, or if they’re lacking one, once they leave our care. It’s a tough call to make, but it’s crucial to get it right.

Social factors – such as housing instability, isolation, substance use, and health literacy – also need to be taken into consideration. These aren’t peripheral; they’re central. They shape presentation, compliance, and outcome.

The current reality is that emergency departments (EDs) across the country are under pressure. That’s an understatement. Overcrowding, access block, and staffing constraints aren’t abstract issues. GPs know this. They hear it from patients who’ve waited hours to be seen and sometimes days on a hospital trolley waiting for an inpatient bed. They see it in discharge summaries that arrive late or not at all. They feel it in the subtle, sometimes not-so-subtle, feed-back that referrals should be “more appropriate”, “more selective”, “better filtered”. And yet, when faced with uncertainty, caution wins. It has to.

No doctor wants to send a patient to the ED unless it’s really necessary. This can disrupt the patient’s care and make it harder for them to get the help they need. It’s like their care gets broken into pieces and it’s not good for the patient.

Also, EDs are invariably very busy and overwhelmed, which can be scary for some patients. But if a doctor doesn’t send a patient to the ED and the patient gets worse, that’s a big problem.

So, the number of ED referrals is rising. It’s not just because doctors are trying to cover themselves, although that is part of it. The truth is, things have changed. The patients are different now, and they’re of- ten sicker. The risks are greater and there’s less of a safety net to catch them if something goes wrong.

A referral that turns out to be benign isn’t necessarily wrong. It reflects a threshold – a decision point – that prioritised safety over certainty. Retrospective clarity is a luxury. Prospective decision-making is not.

What would help?

Better integration, for a start. Real-time access to diagnostics in the community would shift thresholds. Rapid access clinics, properly resourced and genuinely accessible, could absorb a portion of the grey-zone referrals – the patients who don’t clearly need admission, but can’t safely wait.

Communication matters. Direct lines between GPs and EDs – not just for refer- rals, but for discussion, can refine deci- sion-making. A quick conversation can prevent an unnecessary attendance or, equally important, expedite a necessary one. The unscheduled virtual care service at Cork University Hospital has been a game-changer in this regard.

Feedback is crucial in healthcare. It’s not about finding fault or oversimplifying things, but about giving useful information. What was the outcome for the patient who was sent to a specialist? What was the final diagnosis? Were there any early warning signs that could have been understood in a different way?

This process isn’t about assigning blame, it’s about fine-tuning our approach and making adjustments as needed. By examining what happened, we can learn and improve, which is essential for providing the best possible care.

And then there’s the issue of capacity. As long as general practice and EDs remain under-resourced relative to demand, the tension will persist. GPs will continue to make cautious decisions in an uncertain environment, and EDs will continue to absorb the consequences.

As long as general practice and EDs remain under-resourced relative to demand, the tension will persist

The Mater Private Network Cork’s expanded walk-in emergency department service is
now open Monday to Friday, 8am to 8pm. It operates a two-consultant model, supported by comprehensive medical and surgical rosters, enabling faster access to senior clinical decision-making. For GP referrals or additional information, the team can be contacted on 021 601 3333 or email mpced@materprivate.ie