Using the Manchester triage system for refusing nonurgent patients in the emergency department: A 30-day outcome study

Roger Daglius Dias, MD, MBA, PhD; Izabel Cristina Rios, MD, PhD; Carlos Luis Benites Canhada, MSc; Maria Dolores Galinanes Otero Fernandes, BSW; Leila Suemi Harima Letaif, MD, MBA; Eloisa Bonfá, MD, PhD; Maria Beatriz Moliterno Perondi, MD, MBA

doi:10.5055/jem.2016.0300

Authors

Roger Daglius Dias, MD, MBA, PhD
Izabel Cristina Rios, MD, PhD
Carlos Luis Benites Canhada, MSc
Maria Dolores Galinanes Otero Fernandes, BSW
Leila Suemi Harima Letaif, MD, MBA
Eloisa Bonfá, MD, PhD
Maria Beatriz Moliterno Perondi, MD, MBA

DOI:

https://doi.org/10.5055/jem.2016.0300

Keywords:

nonurgent patients, emergency department overcrowding, triage system

Abstract

Objective: To evaluate the long-term outcomes and satisfaction of nonurgent patients who seek care in the emergency department (ED) and are diverted to primary health services (PHS).

Methods: Data were collected from 264 nonurgent patients diverted from the ED of a tertiary public university hospital in São Paulo, Brazil. The nonurgent patient definition was performed by Manchester triage system version II (MTS-II) associated to medical interview in the triage service. Satisfaction levels were evaluated by telephone interviews. The outcomes were assessed within 30 days after the ED visit.
Results: Based on the MTS-II, 56.4 percent of the diverted patients were classified as green, 34.3 percent as blue, and 9.3 percent as white. Only one patient required a hospital admission and no deaths were registered within 30 days after ED diversion. After diversion, the majority of patients searched for PHS (62.7 percent), 14.4 percent sought out other EDs, and 22.9 percent did not seek out any other health services. Regarding patient satisfaction, 61.9 percent evaluated the triage team as fair, good, or very good.

Conclusions: Our study suggests that diverting nonurgent patients from the ED to PHS may be carried out in a hierarchic system like the Brazilian public healthcare system. The MTS-II can be a useful triage system to support physician in the diverting process. In addition, patient satisfaction with the refusing was reasonable. Future studies should be designed to evaluate patient safety outcomes in a larger sample and in different healthcare systems.

Author Biographies

Roger Daglius Dias, MD, MBA, PhD

Emergency Department, Instituto Central do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; STRATUS Center for Medical Simulation, Harvard Medical School, Brigham and Women’s Hospital, Massachusetts, Boston (current affiliation).

Izabel Cristina Rios, MD, PhD

Emergency Department, Instituto Central do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Department of Preventive Medicine, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

Carlos Luis Benites Canhada, MSc

Emergency Department, Instituto Central do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

Maria Dolores Galinanes Otero Fernandes, BSW

Emergency Department, Instituto Central do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

Leila Suemi Harima Letaif, MD, MBA

Emergency Department, Instituto Central do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

Eloisa Bonfá, MD, PhD

Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

Maria Beatriz Moliterno Perondi, MD, MBA

Emergency Department, Instituto Central do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Emergency Department, Instituto da Criança do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

References

Pitts SR, Pines JM, Handrigan MT, et al.: National trends in emergency department occupancy, 2001 to 2008: Effect of inpatient admissions versus emergency department practice intensity. Ann Emerg Med. 2012; 60: 679–686.

Miro O, Antonio MJ, Jimenez S, et al.: Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med. 1999; 6: 105-107.

Pearce L: Complete turnaround Tears, long trolley waits and a hostile local press characterized A&E in Bath. Nurs Stand. 2002; 16: 16-17.

Trout A, Magnusson AR, Hedges JR: Patient satisfaction investigations and the emergency department. Acad Emerg Med. 2000; 7: 695-709.

Vieth TL, Rhodes KV: The effect of crowding on access and quality in an academic ED. Am J Emerg Med. 2006; 24: 787-794.

Erickson C, McErlean M, Bartfield J, et al.: Relationship between maloccurrence and ED census and staffing. Acad Emerg Med. 2001; 8: 499.

Moskop JC, Sklar DP, Geiderman JM, et al.: Emergency department crowding, part 1-concept, causes, and moral consequences. Ann Emerg Med. 2009; 53: 605-611.

Oredsson S, Jonsson H, Rognes J, et al.: A systematic review of triage-related interventions to improve patient flow in emergency departments. Scand J Trauma Resusc Emerg Med. 2011; 19: 43.

Eitel DR, Rudkin SE, Malvehy MA, et al.: Improving service quality by understanding emergency department flow: A White Paper and position statement prepared for the American Academy of Emergency Medicine. J Emerg Med. 2010; 38(1): 70-79.

Durand AC, Gentile S, Devictor B, et al.: ED patients: How non urgent are they? Systematic review of the emergency medicine literature. Am J Emerg Med. 2011; 29: 333-345.

Richardson LD, Hwang U: Acc ess to care: A review of the emergency medicine literature. Acad Emerg Med. 2001; 8: 1030-1036.

Mistry RD, Brousseau DC, Alessandrini EA: Urgency classification methods for emergency department visits: They measure up? Pediatr Emerg Care. 2008; 24: 870-874.

Williams R: The costs of visits to emergency departments. N Engl J Med. 1996; 334: 642-646.

Simonet D: Cost reduction strategies for emergency services: Insurance role, practice changes and patients accountability. Health Care Anal. 2008; 17: 1-19.

Lang T, Davido A, Diakite B, et al.: Using the hospital emergency department as a regular source of care. Eur J Epidemiol. 1997; 13(2): 223–228.

Backman AS, Blomqvist P, Lagerlund M, et al.: Characteristics of non-urgent patients. Cross-sectional study of emergency department and primary care patients. Scand J Prim Health Care. 2008; 26(3): 181-187.

Gentile S, Vignally P, Durand A-C, et al.: Nonurgent patients in the emergency department? A French formula to prevent misuse. BMC Health Serv Res. 2010; 10: 66.

Honigman LS, Wiler, JL, Rooks S, et al.: National study of non-urgent emergency department visits and associated resource utilization. West J Emerg Med. 2013; 14(6): 623-630.

Santos AP, Freitas P, Martins HM: Manchester triage system version II and resource utilization in emergency department. Emerg Med J. 2013; 31: 148-152.

Lowe RA, Bindman AB, Ulrich SK, et al.: Refusing care to emergency department of patients: Evaluation of published triage guidelines. Ann Emerg Med. 1994; 23(2): 286-293.

Diesburg-Stanwood A, Scott J, Oman K, et al.: Nonemergent ED patients referred to community resources after medical screening examination: Characteristics, medical condition after 72 hours, and use of follow-up services. J Emerg Nurs. 2004; 30(4): 312-317.

Derlet RW, Kinser D, Ray L, et al.: Prospective identification and triage of nonemergency patients out of an emergency department: A 5-year study. Ann Emerg Med. 1995; 25(2): 215-223.

Washington DL, Stevens CD, Shekelle PG, et al.: Next-day care for emergency department users with nonacute conditions. A randomized, controlled trial. Ann Intern Med. 2002; 137(9): 707-714.

Derlet RW, Nishio D, Cole LM, et al.: Triage of patients out of the emergency department: Three-year experience. Am J Emerg Med. 1992; 10(3): 195-199.

Raven MC, Lowe RA, Maselli J, et al.: Comparison of presenting complaint vs discharge diagnosis for identifying “nonemergency” emergency department visits. JAMA. 2013; 309(11): 1145-1153.

Azeredo TR, Guedes HM, Rebelo de Almeida RA, et al.: Efficacy of the Manchester Triage System: A systematic review. Int Emerg Nurs. 2015; 23(2): 47-52.

Cunningham PJ, Clancy CM, Cohen JW, et al.: The use of hospital emergency departments for nonurgent health problems: A national perspective. Med Care Res Rev. 1995; 52: 453-474.