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      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

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          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.

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          Most cited references21

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          Emergency Department Triage Scales and Their Components: A Systematic Review of the Scientific Evidence

          Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED? 2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)? 3. How valid is each triage scale in predicting hospitalization and hospital mortality? A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted. We found ED triage scales to be supported, at best, by limited and often insufficient evidence. The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity).
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            Emergency department crowding, part 2--barriers to reform and strategies to overcome them.

            Part 1 of this 2-article series reviews serious moral problems created by emergency department (ED) crowding. In this second part of the series, we identify and describe operational and financial barriers to resolving the crisis of ED crowding, along with a variety of institutional and public policy strategies proposed or implemented to overcome those barriers. Finally, the article evaluates 2 additional actions designed to address the problem of ED crowding, namely, distribution of a warning statement to ED patients and implementation of a "reverse triage" system for safe early discharge of hospital inpatients.
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              Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners, senior house officers, and registrars.

              To compare outcome and costs of general practitioners, senior house officers, and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type. Prospective intervention study which was later costed. Inner city accident and emergency department in south east London. 4641 patients presenting with primary care problems: 1702 were seen by general practitioners, 2382 by senior house officers, and 557 by registrars. Satisfaction and outcome assessed in subsample of 565 patients 7-10 days after hospital attendance and aggregate costs of hospital care provided. Most patients expressed high levels of satisfaction with clinical assessment (430/562 (77%)), treatment (418/557 (75%)), and consulting doctor's manner (434/492 (88%)). Patients' reported outcome and use of general practice in 7-10 days after attendance were similar: 206/241 (85%), 224/263 (85%), and 52/59 (88%) of those seen by general practitioners, senior house officers, and registrars respectively were fully recovered or improving (chi2 = 0.35, P = 0.840), while 48/240 (20%), 48/268 (18%), and 12/57 (21%) respectively consulted a general practitioner or practice nurse (chi2 = 0.51, P = 0.774). Excluding costs of admissions, the average costs per case were 19.30 pounds, 17.97 pounds, and 11.70 pounds for senior house officers, registrars, and general practitioners respectively. With cost of admissions included, these costs were 58.25 pounds, 44.68 pounds, and 32.30 pounds respectively. Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.
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                Author and article information

                Journal
                Scand J Prim Health Care
                Scand J Prim Health Care
                IPRI
                Scandinavian Journal of Primary Health Care
                Taylor & Francis
                0281-3432
                1502-7724
                June 2017
                08 June 2017
                : 35
                : 2
                : 214-220
                Affiliations
                [a ]Department of General Practice and Primary Health Care, Clinicum of Faculty of Medicine, Helsinki, Finland;
                [b ]Department of Primary Health Care Laboratory Services, Helsinki University Central Hospital, Laboratory Services (HUSLAB), Helsinki, Finland;
                [c ]Department of Emergency Medicine, Helsinki University Hospital, Helsinki, Finland
                Author notes
                CONTACT Timo Kauppila timo.kauppila@ 123456fimnet.fi , timo.kauppila@ 123456helsinki.fi Department of General Practice and Primary Health Care, Clinicum of Faculty of Medicine, (Tukholmankatu 8B), Helsinki, SF-00014 University of Helsinki, Finland
                Author information
                http://orcid.org/0000-0002-6155-0300
                Article
                ipri-35-214
                10.1080/02813432.2017.1333320
                5499323
                28593802
                bec0829a-d575-4b32-bcff-c3c377fd4fba
                © 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 21 August 2016
                : 08 May 2017
                Categories
                Research Articles

                emergency department,primary care,patient grouping,reverse triage

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