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

A Primary Care Emergency Service Reduction Did Not Increase Office-Hour Service Use: A Longitudinal Follow-up Study

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.

Evolution over 11 years of the characteristics of walk-in patients at the emergency department of a university hospital in Brussels

Walk-in patients who do not require urgent treatment at an emergency department (ED) are a known and long-standing problem.

This study aims to investigate the characteristics of walk-in patients visiting the ED over time.

During four days in June 2012, all walk-in patients attending the ED of the University Hospital Brussels between 8 AM and 11 PM were recorded. A similar registration took place in the same ED in June 2001. Patients completed a questionnaire about their characteristics and the reason for the encounter. Data of both study periods were compared.

The mean age of the patients attending the ED was significantly lower in 2001 (40.9 years) than in 2012 (43.9 years) (p=0,02). In 2001, 81% of the participants had Belgian nationality, but in 2012 this proportion increased to 90% (p=0.008). In 2001 as well as in 2012, 21% of the participants had a referral from their family physician (FP) (p=0.9). The proportion of patients that were aware that FP could also handle some emergencies increased from 17% in 2001 to 29% in 2012 (p=0.003). More patients had complaints that begun less than 24h before they attended the ED (48% in 2001 and 58% in 2012) (p=0.03).

The walk-in patients at the ED are getting slightly older and are attending the ED faster after the onset of the complaints. More patients judge their complaints as urgent. However, more patients are getting aware that FP also could handle some emergencies.

Suitability of the German version of the Manchester Triage System to redirect emergency department patients to general practitioner care: a prospective cohort study

OBJECTIVES

To investigate the suitability of the German version of the Manchester Triage System (MTS) as a potential tool to redirect emergency department (ED) patients to general practitioner care. Such tools are currently being discussed in the context of reorganisation of emergency care in Germany.

DESIGN

Prospective cohort study.

SETTING

Single centre University Hospital Emergency Department.

PARTICIPANTS

Adult, non-surgical ED patients.

EXPOSURE

A non-urgent triage category was defined as a green or blue triage category according to the German version of the MTS.

PRIMARY AND SECONDARY OUTCOME MEASURES

Surrogate parameters for short-term risk (admission rate, diagnoses, length of hospital stay, admission to the intensive care unit, in-hospital and 30-day mortality) and long-term risk (1-year mortality).

RESULTS

A total of 1122 people presenting to the ED participated in the study. Of these, 31.9% (n=358) received a non-urgent triage category and 68.1% (n=764) were urgent. Compared with non-urgent ED presentations, those with an urgent triage category were older (median age 60 vs 56 years, p=0.001), were more likely to require hospital admission (47.8% vs 29.6%) and had higher in-hospital mortality (1.6% vs 0.8%). There was no significant difference observed between non-urgent and urgent triage categories for 30-day mortality (1.2% [n=4] vs 2.2% [n=15]; p=0.285) or for 1-year mortality (7.9% [n=26] vs 10.5% [n=72]; p=0.190). Urgency was not a significant predictor of 1-year mortality in univariate (HR=1.35; 95% CI 0.87 to 2.12; p=0.185) and multivariate regression analyses (HR=1.20; 95% CI 0.77 to 1.89; p=0.420).

CONCLUSIONS

The results of this study suggest the German MTS is unsuitable to safely identify patients for redirection to non-ED based GP care.

TRIAL REGISTRATION NUMBER

U1111-1119-7564; Post-results.

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

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.

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

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.

Primary triage nurses do not divert patients away from the emergency department at times of high in-hospital bed occupancy - a retrospective cohort study

BACKGROUND

Emergency department (ED) overcrowding is frequently described in terms of input- throughput and output. In order to reduce ED input, a concept called primary triage has been introduced in several Swedish EDs. In short, primary triage means that a nurse separately evaluates patients who present in the Emergency Department (ED) and either refers them to primary care or discharges them home, if their complaints are perceived as being of low acuity. The aim of the present study is to elucidate whether high levels of in-hospital bed occupancy are associated with decreased permeability in primary triage. The appropriateness of discharges from primary triage is assessed by 72-h revisits to the ED.

METHODS

The study is a retrospective cohort study on administrative data from the ED at a 420-bed hospital in southern Sweden from 2011-2012. In addition to crude comparisons of proportions experiencing each outcome across strata of in-hospital bed occupancy, multivariate models are constructed in order to adjust for age, sex and other factors.

RESULTS

A total of 37,129 visits to primary triage were included in the study. 53.4 % of these were admitted to the ED. Among the cases referred to another level of care, 8.8 % made an unplanned revisit to the ED within 72 h. The permeability of primary triage was not decreased at higher levels of in-hospital bed occupancy. Rather, the permeability was slightly higher at occupancy of 100-105 % compared to <95 % (OR 1.09 95 % CI 1.02-1.16). No significant association between in-hospital bed occupancy and the probability of 72-h revisits was observed.

CONCLUSIONS

The absence of a decreased permeability of primary triage at times of high in-hospital bed occupancy is reassuring, as the opposite would have implied that patients might be denied entry not only to the hospital, but also to the ED, when in-hospital beds are scarce.

Impact of an ABCDE team triage process combined with public guidance on the division of work in an emergency department

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.