1
|
Liedes-Kauppila M, Heikkinen AM, Rahkonen O, Lehto M, Mustonen K, Raina M, Kauppila T. Development of the use of primary health care emergency departments after interventions aimed at decreasing overcrowding: a longitudinal follow-up study. BMC Emerg Med 2022; 22:108. [PMID: 35701736 PMCID: PMC9195435 DOI: 10.1186/s12873-022-00667-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background This study, conducted in a Finnish city, examined whether decreasing emergency department (ED) services in an overcrowded primary care ED and corresponding direction to office-hours primary care would modify service usage for specific gender, age or diagnosis groups. Methods This was an observational retrospective study carried out by gradually decreasing ED services in primary care. The interventions aimed at decreasing use of EDs were a) application of ABCDE-triage combined with public guidance on the proper use of EDs, b) closure of a minor supplementary ED, and finally, c) application of “reverse triage” with enhanced direction of the public to office-hours services and away from the remaining ED The annual number of visits to office-hours primary care GPs in different gender, age and diagnosis groups (International Classification of Diseases (ICD − 10) were recorded during a 13-year follow-up period. Results The total number of monthly visits to EDs decreased slowly over the whole study period. This decrease was similar in women and men. The decrease was stronger in the youngest age groups (0–19 years). GPs treated decreasing proportions of ICD-10 groups. Recorded infectious diseases (Groups A and J, and especially diagnoses related to infections of respiratory airways) tended to decrease. However, visits due to injuries and symptomatic diagnoses increased. Conclusion Decreasing services in a primary health care ED with the described interventions seemed to reduce the use of services by young people. The three interventions mentioned above had the effect of making the primary care ED under study appear to function more like a standard ED driven by specialized health care.
Collapse
Affiliation(s)
- Marja Liedes-Kauppila
- Department of Public Health, University of Helsinki, Finland, Biomedicum 2, Tukholmankatu 8 B, SF-00014 Helsingin yliopisto, Helsinki, Finland
| | - Anna M Heikkinen
- Department of Public Health, University of Helsinki, Finland, Biomedicum 2, Tukholmankatu 8 B, SF-00014 Helsingin yliopisto, Helsinki, Finland.,Department of Oral and Maxillofacial Diseases, Head and Neck Center, University of Helsinki, Helsinki, Finland
| | - Ossi Rahkonen
- Department of Public Health, University of Helsinki, Finland, Biomedicum 2, Tukholmankatu 8 B, SF-00014 Helsingin yliopisto, Helsinki, Finland
| | - Mika Lehto
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Vantaa Health Centre, Vantaa, Finland
| | - Katri Mustonen
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Timo Kauppila
- Department of Public Health, University of Helsinki, Finland, Biomedicum 2, Tukholmankatu 8 B, SF-00014 Helsingin yliopisto, Helsinki, Finland.
| |
Collapse
|
2
|
Lehto M, Mustonen K, Raina M, Kauppila T. Differences between recorded diagnoses of patients of an emergency department and office-hours primary care doctors: a register-based study in a Finnish town. Int J Circumpolar Health 2021; 80:1935593. [PMID: 34077332 PMCID: PMC8174484 DOI: 10.1080/22423982.2021.1935593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
To determine the extent to which it is possible to provide continuity of primary care for those who visit Emergency Departments (EDs) we studied how recorded diagnoses in primary care differ, depending on whether the patient is met in an ED or a primary care office-hours practice. In the present, 12-year follow-up study a report generator of the Electronic Health Record-system provided monthly figures for the number of different recorded diagnoses using the International Classification of Diagnoses (10thedition, ICD-10) and the total number of ED doctors and office-hour visits to General Practitioners (GPs). The 20 most common diagnoses covered 48.1% of the visits with recorded diagnoses to the office hour GPs and 45.9% of the visits to the doctors of the ED. Of these 20 diagnoses, 10 were common in both systems. These 10 diagnoses constituted about 30% of the diagnoses given by ED doctors. Furthermore, five out of the six most common diagnoses were the same in the ED and office-hours practices. The doctors in EDs and office-hour GPs treat quite similar patient material. This may provide organisational ways to reorganise the work of primary care and to guarantee continuity of care for those who may benefit from it.
Collapse
Affiliation(s)
- Mika Lehto
- City of Vantaa, Vantaa, Finland.,Department of General Practice, University of Helsinki, Helsinki, Finland
| | - Katri Mustonen
- Department of General Practice, University of Helsinki, Helsinki, Finland
| | | | - Timo Kauppila
- Department of General Practice, University of Helsinki, Helsinki, Finland.,Department of Oral and Maxillofacial Diseases, Head and Neck Center, University of Helsinki, Helsinki, Finland.,Department of General Practice, University of Tampere, Tampere, Finland
| |
Collapse
|
3
|
Lehto M, Pitkälä K, Rahkonen O, Laine MK, Raina M, Kauppila T. The influence of electronic reminders on recording diagnoses in a primary health care emergency department: a register-based study in a Finnish town. Scand J Prim Health Care 2021; 39:113-122. [PMID: 33851565 PMCID: PMC8293956 DOI: 10.1080/02813432.2021.1910449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE This study examines whether implementation of electronic reminders is associated with a change in the amount and content of diagnostic data recorded in primary health care emergency departments (ED). DESIGN A register-based 12-year follow-up study with a before-and-after design. SETTING This study was performed in a primary health care ED in Finland. An electronic reminder was installed in the health record system to remind physicians to include the diagnosis code of the visit to the health record. SUBJECTS AND MAIN OUTCOME MEASURES The report generator of the electronic health record-system provided monthly figures for the number of different recorded diagnoses by using the International Classification of Diagnoses (ICD-10th edition) and the total number of ED physician visits, thus allowing the calculation of the recording rate of diagnoses on a monthly basis and the comparison of diagnoses before and after implementing electronic reminders. RESULTS The most commonly recorded diagnoses in the ED were acute upper respiratory infections of various and unspecified sites (5.8%), abdominal and pelvic pain (4.8%), suppurative and unspecified otitis media (4.5%) and dorsalgia (4.0%). The diagnosis recording rate in the ED doubled from 41.2 to 86.3% (p < 0.001) after the application of electronic reminders. The intervention especially enhanced the recording rate of symptomatic diagnoses (ICD-10 group-R) and alcohol abuse-related diagnoses (ICD-10 code F10). Mental and behavioural disorders (group F) and injuries (groups S-Y) were also better recorded after this intervention. CONCLUSION Electronic reminders may alter the documentation habits of physicians and recording of clinical data, such as diagnoses, in the EDs. This may be of use when planning resource managing in EDs and planning their actions.KEY POINTSElectronic reminders enhance recording of diagnoses in primary care but what happens in emergency departments (EDs) is not known.Electronic reminders enhance recording of diagnoses in primary care ED.Especially recording of symptomatic diagnoses and alcohol abuse-related diagnoses increased.
Collapse
Affiliation(s)
- Mika Lehto
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Vantaa Health Centre, City of Vantaa, Finland
| | - Kaisu Pitkälä
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ossi Rahkonen
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Merja K. Laine
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Centre, Helsinki, Finland
| | - Marko Raina
- Vantaa Health Centre, City of Vantaa, Finland
| | - Timo Kauppila
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Vantaa Health Centre, City of Vantaa, Finland
- CONTACT Timo Kauppila Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Biomedicum 2, Tukholmankatu 8 B FI-00014, Helsinki, Finland
| |
Collapse
|
4
|
Janhunen K, Kankkunen P, Kvist T. Pediatric emergency care: Associations between process factors and outcomes - Children's and parents' views combined with register data. Int Emerg Nurs 2020; 54:100937. [PMID: 33188948 DOI: 10.1016/j.ienj.2020.100937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/22/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Care quality in hospital units can be assessed based on three elements: structure, process, and outcomes. Relationships between elements are particularly important but have largely been unexplored. PURPOSE The purpose of the study was to investigate the relationships between factors of the emergency care process, length of stay, and care outcomes (i.e. care quality and patient satisfaction). METHODS Medical and administrative registry data from children's visits were combined with cross-sectional survey data and analyzed using descriptive methods, median test, and linear regression. Eighty-nine child-parent pairs from four emergency departments participated. RESULTS The shortest length of stay had children at the lowest triage level (p < 0.001) Children with more diagnostic tests (p < 0.001) and more procedures (p < 0.001) performed had the longest length of stay. In linear regression analysis (f = 6.626, df = 6, p = 0.001, R2 = 0.214), the satisfaction of child-parent pairs was associated with performance of more tests and procedures, higher triage levels, and child streaming onto the pediatrician care track. CONCLUSIONS Care process factors affect length of children's stay in emergency departments and could predict children's and parents' satisfaction with, and evaluations of, care quality.
Collapse
Affiliation(s)
- Katja Janhunen
- University of Eastern Finland, Department of Nursing Science, P.O. Box 1627, 70211 Kuopio, Finland.
| | - Päivi Kankkunen
- Department of Nursing Science, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland.
| | - Tarja Kvist
- Department of Nursing Science, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland.
| |
Collapse
|
5
|
Lehto M, Mustonen K, Kantonen J, Raina M, Heikkinen AMK, Kauppila T. A Primary Care Emergency Service Reduction Did Not Increase Office-Hour Service Use: A Longitudinal Follow-up Study. J Prim Care Community Health 2020; 10:2150132719865151. [PMID: 31354021 PMCID: PMC6664635 DOI: 10.1177/2150132719865151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study, conducted in a Finnish city, examined whether decreasing emergency
department (ED) services in an overcrowded primary care ED and corresponding
direction to office-hour primary care would guide patients to office-hour visits
to general practitioners (GP). This was an observational retrospective study
based on a before-and-after design carried out by gradually decreasing ED
services in primary care. The interventions were (a)
application of ABCDE-triage combined with public guidance on the proper use of
EDs, (b) cessation of a minor supplementary ED, and finally
(c) application of “reverse triage” with enhanced direction
of the public to office-hour services from the remaining ED. The numbers of
visits to office-hour primary care GPs in a month were recorded before applying
the interventions fully (preintervention period) and in the postintervention
period. The putative effect of the interventions on the development rate of
mortality in different age groups was also studied as a measure of safety. The
total number of monthly visits to office-hour GPs decreased slowly over the
whole study period without difference in this rate between pre- and
postintervention periods. The numbers of office-hour GP visits per 1000
inhabitants decreased similarly. The rate of monthly visits to office-hour
GP/per GP did not change in the preintervention period but decreased in the
postintervention period. There was no increase in the mortality in any of the
studied age groups (0-19, 20-64, 65+ years) after application of the ED
interventions. There is no guarantee that decreasing activity in a primary care
ED and consecutive enhanced redirecting of patients to the office-hour primary
care systems would shift patients to office-hour GPs. On the other hand, this
decrease in the ED activity does not seem to increase mortality either.
Collapse
Affiliation(s)
| | - Katri Mustonen
- 2 Department of General Practice, University of Helsinki, Helsinki, Finland
| | | | | | | | - Timo Kauppila
- 1 City of Vantaa, Vantaa, Finland.,2 Department of General Practice, University of Helsinki, Helsinki, Finland.,3 University of Tampere, Tampere, Finland
| |
Collapse
|
6
|
Malmström T, Harjola VP, Torkki P, Kumpulainen S, Malmström R. Triage quality control is missing tools-a new observation technique for ED quality improvement. Int J Qual Health Care 2017; 29:295-300. [PMID: 28339735 DOI: 10.1093/intqhc/mzx017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 02/06/2017] [Indexed: 11/13/2022] Open
Abstract
Objective Correct assessment of patient urgency is critical to ensuring patient safety in emergency departments (EDs). Although significant time and effort have been devoted to developing triage systems, less attention has been paid to the development of quality control. The aim of this study is to introduce and test observation technique, which enables identifying of patient groups at risk of erroneous assessment in triage. The introduced technique is aimed to be less laborious to use than existing triage quality control methods. Design The study developed an observation technique for identifying patients with possible erroneous assessments in triage. Data sample for the observation technique is carried out with survey form filled in by nurse. Setting Hospital ED with ~74 000 patient visits annually. Participants Consecutive adult patients in an ED for baseline study period of 14 days (1774 patients) in 2010 and control study period of 4 days (541 patients) in 2012. Intervention Triage observation technique for continuous improvement of triage performance. Main Outcome Measures Primary measures of triage improvement were triage accuracy and nurses' ability to predict patient admissions. Results With the observation technique the ED staff was able to identify patient groups at risk for erroneous triage. Under-triage related mostly to patients with chest pain, shortness of breath, collapse, stomach pain and infections. Instead injures and muscular skeletal symptoms were seldom undertriaged even though they are common. Conclusions EDs can control triage quality with simple observation technique. The usability of observation technique and triage quality improvement process were good.
Collapse
Affiliation(s)
- Tomi Malmström
- Department of Industrial Engineering and Management, Aalto University, Otaniementie 17, PO Box 15500 Espoo, Finland
| | - Veli-Pekka Harjola
- Division of Emergency Care, Helsinki University Central Hospital, Stenbäckinkatu 9, PO Box 100 Helsinki, Finland
| | - Paulus Torkki
- Department of Industrial Engineering and Management, Aalto University, Otaniementie 17, PO Box 15500 Espoo, Finland
| | - Salla Kumpulainen
- Division of Emergency Care, Helsinki University Central Hospital, Stenbäckinkatu 9, PO Box 100 Helsinki, Finland
| | - Raija Malmström
- Hospital District of Helsinki and Uusimaa, Joint Authority, Stenbäckinkatu 9, PO Box 100 Helsinki, Finland
| |
Collapse
|
7
|
Lehtovuori T, Raina M, Suominen L, Kauppila T. A comparison of the effects of electronic reminders and group bonuses on the recording of diagnoses in primary care: a longitudinal follow-up study. BMC Res Notes 2017; 10:700. [PMID: 29208053 PMCID: PMC5718089 DOI: 10.1186/s13104-017-3054-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/30/2017] [Indexed: 11/10/2022] Open
Abstract
Objective To improve the recording of diagnoses in visits to general practitioners, an observational retrospective study based on a before-after design was performed by installing an electronic reminder in the computerized patient chart system, reinforced in feedback delivered in superior-subordinate or development discussions with the general practitioners. The monthly rate of recording diagnoses was observed before and after the intervention. The effect of this intervention on recording of diagnoses was compared with the effects of financial group bonuses on the same parameter in a neighbouring city. Results Before intervention, the level of recording diagnoses was about 45% in the primary care units. Nine months after this intervention there was not yet any statistically significant increase in recording of diagnoses but after 21 months it yielded a recording rate of 90% (P < 0.001). In three years, this percentage reached level over 95%. Group bonuses, a financial incentive serving as a control intervention, increased this parameter from 50 to 80% (P < 0.001) in nine months, and in 21 months the level of recording diagnoses was 90%. The both methods increased the level of recording diagnoses at the same level. Group bonuses acted faster but were also more expensive.
Collapse
Affiliation(s)
| | | | | | - Timo Kauppila
- , Peltolantie 2, 01300, Vantaa, Finland. .,Department of General Practice and Primary Health Care, HUS, Institute of Clinical Medicine, University of Helsinki, P.O. Box 20, Tukholmankatu 8 B, 00014, Helsinki, Finland.
| |
Collapse
|
8
|
Mustonen K, Kantonen J, Kauppila T. The effect on the patient flow in local health care services after closing a suburban primary care emergency department: a controlled longitudinal follow-up study. Scand J Trauma Resusc Emerg Med 2017; 25:116. [PMID: 29183366 PMCID: PMC5706306 DOI: 10.1186/s13049-017-0460-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 11/20/2017] [Indexed: 11/10/2022] Open
Abstract
Background It has not been studied what happens to patient flow to EDs and other parts of local health care system if distances to ED services are manipulated as a part of health policy in urban areas. Methods The present work was an observational and quasi-experimental study with a control and it was based on before-after comparisons. The impact of terminating a geographically distant suburban primary care ED on patient flow to doctors in local public primary care EDs, office-hour primary care, secondary care EDs and in private primary care was studied. The effect of this intervention was compared with a primary care system where no similar intervention was performed. The number of monthly visits to doctors in different departments of health care was scored as the main measure of the study in each department studied (e.g. in primary care EDs, secondary care ED, office-hour public primary care and private primary care). Monthly mortality rates were also recorded. Results Increasing the distance to ED services by terminating a peripheral ED did not cause an increase in the use of local office-hour services in those areas whose local ED was terminated, although use of ED services decreased by 25% in these areas (P < 0.001). The total use of primary care doctor services rather decreased - if anything - after this intervention while use of doctor services in secondary care ED remained unaffected. Doctor visits to the complementary private primary care increased but this was probably not associated with the intervention because a simultaneous increase in this parameter was observed in the control. There was no increased mortality in any age groups. Conclusion Manipulating distances to ED services can be used to direct patient flows to different parts of the health care system. The correlation between distance to ED and the tendency to use ED by inhabitants is negative. If secondary care ED was available there were no life-threatening side-effects at the level of general public health when a minor ED was closed in a primary care ED system.
Collapse
Affiliation(s)
- Katri Mustonen
- Department of Primary Health Care Laboratory Services, Helsinki University Central Hospital, Laboratory Services (HUSLAB), Topeliuksenkatu 32, 00029 HUS, Helsinki, Finland
| | - Jarmo Kantonen
- Primary Health Care, City of Vantaa, Peltolantie 2D, 01300, Vantaa, Finland
| | - Timo Kauppila
- Primary Health Care, City of Vantaa, Peltolantie 2D, 01300, Vantaa, Finland. .,Department of General Practice and Primary Health Care, Clinicum of Faculty of Medicine, University of Helsinki, (Tukholmankatu 8B), -00014, Helsinki, SF, Finland.
| |
Collapse
|
9
|
Kauppila T, Seppänen K, Mattila J, Kaartinen J. The effect on the patient flow in a local health care after implementing reverse triage in a primary care emergency department: a longitudinal follow-up study. Scand J Prim Health Care 2017; 35:214-220. [PMID: 28593802 PMCID: PMC5499323 DOI: 10.1080/02813432.2017.1333320] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor's list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors' services in collaborative parts of the health care system. DESIGN An observational study. SETTING Register-based retrospective quasi-experimental longitudinal follow-up study based on a before-after setting in a Finnish city. SUBJECTS Patients who consulted different doctors in a local health care unit. MAIN OUTCOME MEASURES Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage. RESULTS The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased. CONCLUSIONS The data suggested that the reverse triage causes redistribution of the use of doctors' services rather than a true decrease in the use of these services.
Collapse
Affiliation(s)
- Timo Kauppila
- Department of General Practice and Primary Health Care, Clinicum of Faculty of Medicine, Helsinki, Finland
- CONTACT Timo Kauppila , Department of General Practice and Primary Health Care, Clinicum of Faculty of Medicine, (Tukholmankatu 8B), Helsinki, SF-00014 University of Helsinki, Finland
| | - Katri Seppänen
- Department of Primary Health Care Laboratory Services, Helsinki University Central Hospital, Laboratory Services (HUSLAB), Helsinki, Finland
| | - Juho Mattila
- Department of Emergency Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Johanna Kaartinen
- Department of Emergency Medicine, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
10
|
Lehtovuori T, Kauppila T, Kallio J, Raina M, Suominen L, Heikkinen AM. Financial team incentives improved recording of diagnoses in primary care: a quasi-experimental longitudinal follow-up study with controls. BMC Res Notes 2015; 8:668. [PMID: 26559491 PMCID: PMC4642783 DOI: 10.1186/s13104-015-1602-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 10/19/2015] [Indexed: 11/29/2022] Open
Abstract
Background In primary care, financial incentives have usually been directed to physicians because they are thought to make the key decisions in order to change the functions of a medical organization. There are no studies regarding the impact that directing these incentives to all disciplines of the care team (e.g. group bonuses for both nurses and doctors) may have, despite the low frequency with which diagnoses were being recorded for primary care visits to doctors. This study tested the effect of offering group bonuses to the care teams. Methods This was a retrospective quasi-experimental study with before-and-after settings and two control groups. In the intervention group, the mean percentage of visits to a doctor for which a diagnosis was recorded by each individual care team (mean team-based percentage of monthly visits to a doctor with recorded diagnoses) and simultaneously the same data was gathered from two different primary care settings where no team bonuses were applied. To study the sustainability of changes obtained with the group bonuses the respective data were derived from the electronic health record system for 2 years after the cessation of the intervention. The differences in the rate of marking diagnoses was analyzed with ANOVA and RM-ANOVA with appropriate post hoc tests, and the differences in the rate of change in marking diagnoses was analyzed with linear regression followed by t-test. Results The proportion of doctor visits having recorded diagnoses in the teams was about 55 % before starting to use group bonuses and 90 % after this intervention. There was no such increase in control units. The effect of the intervention weakened slightly after cessation of the group bonuses. Conclusion Group bonuses may provide a method to alter clinical practices in primary care. However, sustainability of these interventions may diminish after ceasing this type of financial incentive.
Collapse
Affiliation(s)
| | - Timo Kauppila
- Department of General Practice and Primary Healthcare, HUS, Institute of Clinical Medicine, University of Helsinki, P.O. Box 20, Tukholmankatu 8 B, 00014, Vantaa, Finland.
| | | | | | | | - Anna Maria Heikkinen
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Espoo, Finland.
| |
Collapse
|
11
|
Kantonen J, Lloyd R, Mattila J, Kauppila T, Menezes R. Impact of an ABCDE team triage process combined with public guidance on the division of work in an emergency department. Scand J Prim Health Care 2015; 33:74-81. [PMID: 25968180 PMCID: PMC4834506 DOI: 10.3109/02813432.2015.1041825] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To study the effects of applying an emergency department (ED) triage system, combined with extensive publicity in local media about the "right" use of emergency services, on the division of work between ED nurses and general practitioners (GPs). DESIGN An observational and quasi-experimental study based on before-after comparisons. SETTING Implementation of the ABCDE triage system in a Finnish combined ED where secondary care is adjacent, and in a traditional primary care ED where secondary care is located elsewhere. SUBJECTS GPs and nurses from two different primary care EDs. MAIN OUTCOME MEASURES Numbers of monthly visits to different professional groups before and after intervention in the studied primary care EDs and numbers of monthly visits to doctors in the local secondary care ED. RESULTS The beginning of the triage process increased temporarily the number of independent consultations and patient record entries by ED nurses in both types of studied primary care EDs and reduced the number of patient visits to a doctor compared with previous years but had no effect on doctor visits in the adjacent secondary care ED. No further decrease in the number of nurse or GP visits was observed by inhibiting the entrance of non-urgent patients. CONCLUSION The ABCDE triage system combined with public guidance may reduce non-urgent patient visits to doctors in different kinds of primary care EDs without increasing visits in the secondary care ED. However, the additional work to implement the ABCDE system is mainly directed to nurses, which may pose a challenge for staffing.
Collapse
Affiliation(s)
| | - Robert Lloyd
- Institute for Healthcare Improvement, Boston, MA, USA
| | - Juho Mattila
- Helsinki University Central Hospital, HUS, Helsinki, Finland
| | - Timo Kauppila
- Department of General Practice and Primary Healthcare, HUS, Institute of Clinical Medicine, and University of Helsinki, Finland
- Correspondence: Timo Kauppila, MD DMSc, Reader, Department of General Practice and Primary Healthcare, HUS, Institute of Clinical Medicine, and University of Helsinki, PO Box 20 (Tukholmankatu 8 B), 00014 University of Helsinki, Finland. Tel: + 358 9 1911, + 358 44 7684449. Fax: + 358 9 191 27536.
| | - Ricardo Menezes
- Emergency unit project, Jorvi Hospital, Puolarmetsä Hospital, Espoo, Medivida LTD, Helsinki, Finland
| |
Collapse
|
12
|
Mattsson MS, Mattsson N, Jørsboe HB. Improvement of clinical quality indicators through reorganization of the acute care by establishing an emergency department-a register study based on data from national indicators. Scand J Trauma Resusc Emerg Med 2014; 22:60. [PMID: 25370418 PMCID: PMC4226916 DOI: 10.1186/s13049-014-0060-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 10/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background The Emergency Departments (EDs) reorganization process in Denmark began in 2007 and includes creating a single entrance for all emergency patients, establishing triage, having a specialist in the front and introducing the use of electronic overview boards and electronic patient files. The aim of this study was to investigate the quality of acute care in a re-organized ED based on national indicator project data in a pre and post reorganizational setting. Methods Quasi experimental design was used to examine the effect of the health care quality in relation to the reorganization of an ED. Patients admitted at Nykøbing Falster Hospital in 2008 or 2012 were included in the study and data reports from the national databases (RKKP) regarding stroke, COPD, heart failure, bleeding and perforated ulcer or hip fracture were analysed. Holbæk Hospital works as a control hospital. Chi-square test was used for analysing significant differences from pre-and post intervention and Z-test to compare the experimental groups to the control group (HOL). P < 0.05 was considered statistically significant. Results We assessed 4584 patient cases from RKKP. A significant positive change was seen in all of the additional eight indicators related to stroke at NFS (P < 0.001); however, COPD indicators were unchanged in both hospitals. In NFS two of eight heart failure indicators were significantly improved after the reorganization (p < 0.01). In patients admitted with a bleeding ulcer 2 of 5 indicators were significantly improved after the reorganization in NFS and HOL (p < 0.01). Both compared hospitals showed significant improvements in the two indicators concerning hip fracture (p < 0.001). Significant reductions in the 30 day-mortality in patients admitted with stroke were seen when the pre- and the post-intervention data were compared for both NFS and HOL (p = 0.024). Conclusions During the organisation of the new EDs, several of the indicators improved and the overall 30 days mortality decreased in the five diseases. The development of a common set of indicators for monitoring acute treatment at EDs in Denmark is recommended.
Collapse
Affiliation(s)
- Maria Søe Mattsson
- Faculty of Health Science, University of Southern Denmark, 5230, Odense M, Denmark. .,Emergency Department, Hospital of Nykøbing Falster, 4800, Nykøbing Falster, Denmark.
| | - Nick Mattsson
- Emergency Department, Hospital of Nykøbing Falster, 4800, Nykøbing Falster, Denmark. .,Department of Cardiology, Bispebjerg Hospital, 2400, Copenhagen, NV, Denmark.
| | - Hanne B Jørsboe
- Emergency Department, Hospital of Nykøbing Falster, 4800, Nykøbing Falster, Denmark.
| |
Collapse
|
13
|
Taye BW, Yassin MO, Kebede ZT. Quality of emergency medical care in Gondar University Referral Hospital, Northwest Ethiopia: a survey of patients' perspectives. BMC Emerg Med 2014; 14:2. [PMID: 24456203 PMCID: PMC3902003 DOI: 10.1186/1471-227x-14-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 01/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ethiopia has fairly good coverage but very low utilization of health care services. Emergency medical care services require fast, correct and curious services to clients as they present with acute problems. In Ethiopia and Gondar in particular, the quality of emergency medical care has not been studied. The main aim of this study was to assess the disease profile and patients' satisfaction in Gondar University Referral Hospital (GURH). METHODS A facility based cross-sectional study was conducted among patients visiting GURH for emergency care. Ethical clearance was obtained from the Institutional Review Board of University of Gondar. Patients were selected by systematic random sampling, using patient flow list in the day and night emergency services. Data were collected using a standard Press Ganey questionnaire by BSc health science graduates. Data were entered in to Epi Info 3.5.3 software and exported to SPSS version 20.0 for windows for analysis. RESULTS A total of 963 patients (response rate = 96.8%) were studied. The mean (+ s.d.) age of patients was 28.4 (+17.9) years. The overall satisfaction using the mean score indicates that 498 (51.7%) 95%CI: (48.4% - 54.9%) were satisfied with the service, the providers and the facility suitability whereas 465(48.3%) 95%CI: (45.1%- 51.6%) were not satisfied. Seven hundred and six (73.3%) 95%CI: 70.4%-76.1%, patients reported that they have been discriminated or treated badly during the service provision in the hospital. OPD site visited (p < 0.0001), visiting days of the week (P < 0.049), medical condition on arrival (P < 0.0001), degree of confidence in the hospital (AOR = 1.9, 95%CI: 1.1, 3.1), reported discrimination/bad treatment of patients with service (AOR = 0.4, 95%CI: 0.2, 0.7), were significantly associated determinants of patient satisfaction. CONCLUSIONS Non-communicable disease emergencies like injuries and cardiovascular diseases are common. There is a low level of patient satisfaction related to lack of confidence in the hospital for treatment, discrimination towards patient care, and under and delayed treatment of patients who were not in serious medical conditions. Hospitals shall prepare themselves to address the increasing challenge of non-communicable disease emergencies. It is important to revise the service delivery in the emergency department to improve staff courtesy and politeness, commitment, reduce discrimination and bad treatment and proper triage of emergencies at all points of care to increase patient satisfaction giving emphasis to earlier working days.
Collapse
Affiliation(s)
- Belaynew Wasie Taye
- Department of Epidemiology and Biostatistics, Bahir Dar University, Bahir Dar, Ethiopia.
| | | | | |
Collapse
|
14
|
Impact of the ABCDE triage in primary care emergency department on the number of patient visits to different parts of the health care system in Espoo City. BMC Emerg Med 2012; 12:2. [PMID: 22217300 PMCID: PMC3267646 DOI: 10.1186/1471-227x-12-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 01/04/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland. METHODS The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital). A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse). The introduction of this triage system was combined with information to the public on the "correct" use of emergency services. RESULTS After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month) as compared to the three previous years in the EDs. The Number of visits to public sector GPs during office hours did not alter. Implementation of ABCDE-triage combined with public guidance was associated with decreased total number of doctor visits in public health care. During same period, the number of patient visits in the private health care increased. Simultaneously, the number of doctor visits in secondary health care ED did not alter. CONCLUSIONS The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the secondary health care EDs. Limiting the access of less urgent patients to ED may redirect the demands of patients to private sector rather than office hours GP services.
Collapse
|
15
|
Farrokhnia N, Göransson KE. Swedish emergency department triage and interventions for improved patient flows: a national update. Scand J Trauma Resusc Emerg Med 2011; 19:72. [PMID: 22151969 PMCID: PMC3285084 DOI: 10.1186/1757-7241-19-72] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 12/08/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Scandinavia, emergency department triage and patient flow processes, are under development. In Sweden, the triage development has resulted in two new triage scales, the Adaptive Process Triage and the Medical Emergency Triage and Treatment System. Both these scales have logistic components, aiming to improve patient flows. The aim of this study was to report the development and current status of emergency department triage and patient flow processes in Sweden. METHODS In 2009 and 2010 the Swedish Council on Health Technology Assessment sent out a questionnaire to the ED managers in all (74) Swedish hospital emergency departments. The questionnaire comprised questions about triage and interventions to improve patient flows. RESULTS Nearly all (97%) EDs in Sweden employed a triage scale in 2010, which was an increase from 2009 (73%). Further, the Medical Emergency Triage and Treatment System was the triage scale most commonly implemented across the country. The implementation of flow-related interventions was not as common, but more than half (59%) of the EDs have implemented or plan to implement nurse requested X-ray. CONCLUSIONS There has been an increase in the use of triage scales in Swedish EDs during the last few years, with acceleration for the past two years. Most EDs have come to use the Medical Emergency Triage and Treatment System, which also indicates regional co-operation. The implementation of different interventions for improved patient flows in EDs most likely is explained by the problem of crowding. Generally, more studies are needed to investigate the economical aspects of these interventions.
Collapse
Affiliation(s)
- Nasim Farrokhnia
- Department of Medical Sciences, Uppsala University, ingång 40, 5 trp, 751 85 Academic Hospital, Uppsala, Sweden.
| | | |
Collapse
|