Triaging and referring in adjacent general and emergency departments (the TRIAGE trial): A cluster randomised controlled trial

Stefan Morreel, Hilde Philips, Diana De Graeve, Koenraad G Monsieurs, Jarl K Kampen, Jasmine Meysman, Eva Lefevre, Veronique Verhoeven, Stefan Morreel, Hilde Philips, Diana De Graeve, Koenraad G Monsieurs, Jarl K Kampen, Jasmine Meysman, Eva Lefevre, Veronique Verhoeven

Abstract

Objectives: To determine whether a new triage system safely diverts a proportion of emergency department (ED) patients to a general practitioner cooperative (GPC).

Methods: Unblinded randomised controlled trial with weekends serving as clusters (three intervention clusters for each control). The intervention was triage by a nurse using a new extension to the Manchester Triage System assigning low-risk patients to the GPC. During intervention weekends, patients were encouraged to follow this assignment; it was not communicated during control weekends (all patients remained at the ED). The primary outcome was the proportion of patients assigned to and handled by the GPC during intervention weekends. The trial was randomised for the secondary outcome: the proportion of patients assigned to the GPC. Additional outcomes were association of these outcomes with possible confounders (study tool parameters, nurse, and patient characteristics), proportion of patients referred back to the ED by the GPC, hospitalisations, and performance of the study tool to detect primary care patients (the opinion of the treating physician was the gold standard).

Results: In the intervention group, 838/6294 patients (13.3%, 95% CI 12.5 to 14.2) were assigned to the GPC, in the control group this was 431/1744 (24.7%, 95% CI 22.7 to 26.8). In total, 599/6294 patients (9.5%, 95% CI 8.8 to 10.3) experienced the primary outcome which was influenced by the reason for encounter, age, and the nurse. 24/599 patients (4.0%, 95% CI 2.7 to 5.9) were referred back to the ED, three were hospitalised. Positive and negative predictive values of the studied tool during intervention weekends were 0.96 (95%CI 0.94 to 0.97) and 0.60 (95% CI 0.58 to 0.62). Out of the patients assigned to the GPC, 2.4% (95% CI 1.7 to 3.4) were hospitalised.

Conclusions: ED nurses using a new tool safely diverted 9.5% of the included patients to primary care.

Trial registration: ClinicalTrials.gov Identifier: NCT03793972.

Conflict of interest statement

I have read the journal’s policy and the authors of this manuscript have the following competing interests: The second author is a general practitioner working in the surroundings of the study site, and as such, he performed on call shifts at the study site and treated some of the studied patients. Due to the anonymity of the studied data, the exact number of study patients seen by him cannot be determined, but it was definitely below ten. He is also a board member of the studied general practice cooperative receiving meeting fees. Author HP is coordinator of the iCAREdata project (database used for this study). She had an appointment at the University of Antwerp for this project until September 2020. The authors declare no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1. Example of a Manchester triage…
Fig 1. Example of a Manchester triage system presentational flowchart with the studied extension.
GP: General Practitioner. PV: Per Vaginam. Image based on Emergency Triage: Mackway-Jones K, Marsden J, Windle J, Manchester Triage Group. Emergency triage. Third edition. Ed, 2014, ISBN 9781118299067 p. 66 with kind permission.
Fig 2. Patient flow through the study…
Fig 2. Patient flow through the study (CONSORT flowchart).
ED: Emergency Department. GPC: General Practice Cooperative. GP: General Practitioner. LWBS: Left Without Being Seen.
Fig 3. Combined chi square aided interaction…
Fig 3. Combined chi square aided interaction detection (CHAID) tree for the primary outcome.
ORL: Otorhinolaryngology. : no MTS flowchart was registered.

References

    1. Kraaijvanger N, Rijpsma D, van Leeuwen H, van Dijk N, Edwards M. Self-referrals in a Dutch Emergency Department: how appropriate are they? Eur J Emerg Med. doi: 10.1097/MEJ.0000000000000216
    1. Derlet RW, Ledesma A. How do prudent laypeople define an emergency medical condition? J Emerg Med. doi: 10.1016/s0736-4679(99)00014-1
    1. Carret ML, Fassa AG, Kawachi I. Demand for emergency health service: factors associated with inappropriate use. BMC Health Serv Res. doi: 10.1186/1472-6963-7-131
    1. Durand A- C, Gentile S, Devictor B, Palazzolo S, Vignally P, Gerbeaux P, et al.. ED patients: how nonurgent are they? Systematic review of the emergency medicine literature. Am J Emerg Med. doi: 10.1016/j.ajem.2010.01.003
    1. Chou SC, Venkatesh AK, Trueger NS, Pitts SR. Primary Care Office Visits For Acute Care Dropped Sharply In 2002–15, While ED Visits Increased Modestly. Health Aff (Millwood). doi: 10.1377/hlthaff.2018.05184
    1. Hyman DA, Studdert DM. Emergency Medical Treatment and Labor Act: What Every Physician Should Know About the Federal Antidumping Law. Chest. doi: 10.1378/chest.14-2046
    1. Hong M, Thind A, Zaric GS, Sarma S. The impact of improved access to after-hours primary care on emergency department and primary care utilization: A systematic review. Health policy. doi: 10.1016/j.healthpol.2020.05.015
    1. Cooper A, Carson-Stevens A, Hughes T, Edwards A. Is streaming patients in emergency departments to primary care services effective and safe? BMJ. doi: 10.1136/bmj.m462
    1. Cooper A, Davies F, Edwards M, Anderson P, Carson-Stevens A, Cooke MW, et al.. The impact of general practitioners working in or alongside emergency departments: a rapid realist review. BMJ open. doi: 10.1136/bmjopen-2018-024501
    1. Goncalves-Bradley D, Khangura JK, Flodgren G, Perera R, Rowe BH, Shepperd S. Primary care professionals providing non-urgent care in hospital emergency departments. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD002097.pub4
    1. Schoenmakers B, Van Criekinge J, Boeve T, Wilms J, Van Der Mullen C, Sabbe M. Co-location of out of hours primary care and emergency department in Belgium: patients’ and physicians’ view. BMC Health Serv Res. doi: 10.1186/s12913-021-06281-y
    1. 1991. MeSH subject heading scope. Available from: . MeSH Unique ID: D014218.
    1. Morreel S, Colliers A, Remmen R, Verhoeven V, Philips H. How accurate is telephone triage in out-of-hours care? An observational trial in real patients. Acta Clin Belg. doi: 10.1080/17843286.2020.1839719
    1. Zachariasse JM, Seiger N, Rood PP, Alves CF, Freitas P, Smit FJ, et al.. Validity of the Manchester Triage System in emergency care: A prospective observational study. PLoS One. doi: 10.1371/journal.pone.0170811
    1. van Veen M, Steyerberg EW, Lettinga L, Ruige M, van Meurs AH, van der Lei J, et al.. Safety of the Manchester Triage System to identify less urgent patients in paediatric emergence care: a prospective observational study. Arch Dis Child. doi: 10.1136/adc.2010.199018
    1. van der Straten LM, van Stel HF, Spee FJ, Vreeburg ME, Schrijvers AJ, Sturms LM. Safety and efficiency of triaging low urgent self-referred patients to a general practitioner at an acute care post: an observational study. Emerg Med J. doi: 10.1136/emermed-2011-200539
    1. Dias RD, Rios IC, Canhada CL, Fernandes MD, Letaif LS, Bonfa E, et al.. Using the Manchester triage system for refusing nonurgent patients in the emergency department: A 30-day outcome study. J Emerg Manag. doi: 10.5055/jem.2016.0300
    1. Morreel S, Philips H, Verhoeven V. Self-triage at an urgent care collaboration with and without information campaign. J Emerg Manag. doi: 10.5055/jem.2019.0443
    1. Philips H, Van Bergen J, Huibers L, Colliers A, Bartholomeeusen S, Coenen S, et al.. Agreement on urgency assessment between secretaries and general practitioners: an observational study in out-of-hours general practice service in Belgium. Acta Clin Belg. doi: 10.1179/2295333715Y.0000000017
    1. McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: New concepts are needed to study research participation effects. J Clin Epidemiol. doi: 10.1016/j.jclinepi.2013.08.015
    1. Colliers A, Bartholomeeusen S, Remmen R, Coenen S, Michiels B, Bastiaens H, et al.. Improving Care And Research Electronic Data Trust Antwerp (iCAREdata): a research database of linked data on out-of-hours primary care. BMC Res Notes. doi: 10.1186/s13104-016-2055-x
    1. Bartholomeeusen Stephaan PH, Van Royen Paul, Roy Remmen, Samuel Coenen. iCAREdata: Improving Care And Research Electronic Data Trust Antwerp. Zenodo. doi: 10.5281/zenodo.823697
    1. Morreel S, Philips H, Verhoeven V. Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: A real-time observational study. PLoS One. doi: 10.1371/journal.pone.0237629
    1. Kass GV. An Exploratory Technique for Investigating Large Quantities of Categorical Data. J R Stat Soc Ser C Appl Stat. doi: 10.2307/2986296
    1. Lemon SC, Roy J, Clark MA, Friedmann PD, Rakowski W. Classification and regression tree analysis in public health: methodological review and comparison with logistic regression. Ann Behav Med. doi: 10.1207/S15324796ABM2603_02
    1. The jamovi project (2021). jamovi (Version 1.6) [Computer Software]. Retrieved from
    1. R Core Team (2017). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL .
    1. Roscoe LA, Eisenberg EM, Forde C. The Role of Patients’ Stories in Emergency Medicine Triage. Health Commun. doi: 10.1080/10410236.2015.1046020
    1. van Veelen MJ, van den Brand CL, Reijnen R, van der Linden MC. Effects of a general practitioner cooperative co-located with an emergency department on patient throughput. World J Emerg Med. doi: 10.5847/wjem.j.1920-8642.2016.04.005
    1. van Gils-van Rooij ES, Yzermans CJ, Broekman SM, Meijboom BR, Welling GP, de Bakker DH. Out-of-Hours Care Collaboration between General Practitioners and Hospital Emergency Departments in the Netherlands. J Am Board Fam Med. doi: 10.3122/jabfm.2015.06.140261
    1. Doran KM, Colucci AC, Hessler RA, Ngai CK, Williams ND, Wallach AB, et al.. An Intervention Connecting Low-Acuity Emergency Department Patients With Primary Care: Effect on Future Primary Care Linkage. Ann Emerg Med. doi: 10.1016/j.annemergmed.2012.10.021
    1. Hayward G, Lasserson D, Garland S, Hunt H. Variation in referral rates to emergency departments and inpatient services from a GP Out Of Hours service and the potential impact of alternative staffing models. Emerg Med J. doi: 10.1136/emermed-2020-209527
    1. Rutten M, Vrielink F, Smits M, Giesen P. Patient and care characteristics of self-referrals treated by the general practitioner cooperative at emergency-care-access-points in the Netherlands. BMC Fam Pract. doi: 10.1186/s12875-017-0633-1
    1. Zaboli A, Turcato G, Solazzo P, Sorrento D, Zorzi E, Marsoner T, et al.. Effectiveness of Manchester Triage System in risk prioritisation of patients with pulmonary embolism who present dyspnoea, chest pain or collapse. Int Emerg Nurs. doi: 10.1016/j.ienj.2020.100842
    1. Nishi FA, Polak C, Cruz DdALMd. Sensitivity and specificity of the Manchester Triage System in risk prioritization of patients with acute myocardial infarction who present with chest pain. Eur J Cardiovasc Nurs. doi: 10.1177/1474515118777402
    1. Zaboli A, Ausserhofer D, Pfeifer N, Magnarelli G, Ciccariello L, Siller M, et al.. Acute abdominal pain in triage: A retrospective observational study of the Manchester triage system’s validity. J Clin Nurs. doi: 10.1111/jocn.15635

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