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

Abstract

BackgroundMany 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.MethodsThe 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.ResultsAfter 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.ConclusionsThe 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.

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

“…Administration of primary care may be interested in this intervention due to cost savings produced by decreased use of doctor resources in the cost area of emergency services [ 16 , 27 ]. On the other hand, there seems to be an association between introducing this type of “reverse triage” and increased use of expensive complementary private sector doctors’ services [ 7 , 27 ]. In Finland, private services are mainly available for wealthy people [ 28 ] and increasing their use is not necessarily a desired goal in public health care trying to serve equally the whole population.…”

“…Patients arriving by other means than ambulance end up being directed to a primary health care ED nurse for ABCDE triage. The ABCDE triage [ 7 , 9 , 10 ] was performed by experienced ED nurses in the front line as described previously [ 7 , 10 ].…”

“…Since the triage system was introduced at the beginning of March 2007, the number of patient visits since the introduction of the system was compared with the number of patient visits in the respective months of the years before the intervention. The numbers of monthly visits were initially compared using one-way repeated measures analysis of variance followed by the use of Bonferroni's test for detecting the effects of significant systematic monthly variation [ 7 , 10 ].…”

“…Urgent treatment is compromised if the ED is too crowded [ 5 ]. Internationally, most countries separate primary care and EDs and provide ED services as secondary care functions [ 6 , 7 ] but in Finland primary care and GPs are also involved in ED functions [ 7–10 ]. These primary care EDs are easily accessible, which has led to crowding and overuse of these facilities [ 8 ].…”

“…As an attempt to provide immediate treatment for those patients in primary health care ED who need it the most, a face-to-face triage system [ 7 , 9 , 10 ] was developed in Finland. This type of triage has been reported to reduce visits to doctors in primary care EDs where secondary care EDs are available in the same facilities without increasing the workload of primary care doctors in office hours [ 7 , 10 ]. There are thus no data regarding who treats these ED patients who do not end up with primary care doctors or where such treatment is provided.…”