Triaging and referring in adjacent general and emergency departments (the TRIAGE-trial): A process evaluation of medical staff experiences in a nurse-led triage system

When patients have a medical problem after the GP’s normal office hours they have to fall back on the system of out-of-hours (OOH) care [1]. In an increasing number of European countries, such as the Netherlands, Belgium, France and Denmark, OOH primary care is being organized through large-scale General Practitioners Cooperatives (GPCs), where GP’s from a region group together to replace small rotation groups in order to provide after-hours primary care at a centralized location for face-to-face consultations and house calls, with the support of additional personnel [1], [2], [3]. Hospital Emergency departments (EDs), where patients can receive urgent medical treatment without previous medical referral, work in parallel to these GPCs [4]. Despite the increasing number of GPCs, these EDs do not necessarily experience a reduction in patients. On the contrary, recent research has shown that EDs as well as GPs see an increasing number of patients [5].

In Flanders, patients are free to consult any GP or a specialist for their health problems without specific referral. This freedom of choice is an important characteristic of the Belgian healthcare system [6] and, in combination with the fact that EDs are designed to be convenient for those in need of medical attention [7], makes that the threshold for patients to self-present at the ED after the GP’s normal office hours, even with non-urgent complaints, is very low. This increased level of convenience is recognized as one of the contributing factors to the rising number of ED visits worldwide [8], [9], [10].

Previous studies [4], [11] have shown that, when it comes to OOH care, patients are often not aware of the different characteristics of the respective OOH services. They find it difficult to assess the urgency of their medical problem or illness and subsequently present themselves at the ED [4], [11]. Although a clear definition of what can be considered ‘appropriate’ or ‘inappropriate’ use of an ED is lacking [7], [8], several international studies have reported that many of the presented medical problems at the ED could be managed in primary care [12], [13], [14], [15]. Observational studies have shown that 10 to 40% of self-presenting patients at the ED could be managed in primary care [16], [17], [18], [19], [20]. The aim of the TRIAGE trial was to deliver the most appropriate care for self-presenters at the ED. In this trial, triage nurses assessed self-presenting ED patients aided by a triage protocol based on the Manchester Triage System but extended specifically for this research project. This assessment resulted in an advice concerning the most appropriate point of care for their medical problem: the GPC or ED. At the end of the TRIAGE trial, 13% of the included patients were assigned to the GPC [21].

The evaluation of such a complex triage and streaming process is necessary in order to identify inhibitors and facilitators to its successful adoption [22]. An effective method is process evaluation, which provides insights into why an intervention is successful or not [23], [24]. It explores how the intervention is received by stakeholders, how it is implemented and in what context the trial is set [24]. Depending on the specific scope of the process evaluation, different research methods, both quantitative and qualitative, can be applied [25]. Given the specific focus of this research being the identification of factors that influence the successful implementation of the intervention from the the medical staff’s perspective, a qualitative approach based on interviews was chosen.

In this article, we report the findings of the process evaluation based on the interviews with the ED nurses, ED doctors, and GPs on call at the GPC during the TRIAGE Trial. The TRIAGE trial was conducted in the ED of a general hospital and an adjacent GPC in an suburban area in Flanders, Belgium. The trial, in the form of a cluster randomised controlled trial, started March 1st, 2019 and ended December 31st, 2019. The ratio of intervention and control clusters was three to one. Overall, 8158 patients were included, 6374 during intervention clusters and 1784 during control clusters. During intervention clusters 838 patients (13.3%, 95% CI 12.5 to 14.2) received the advice to be seen in the GPC of which 196 (23.4 %, 95%CI 20.6 to 26.4) refused this advice [26]. Young patients arriving without an ambulance with a typical primary care presentation were more often triaged to the GPC [21].

The implementation of the triage intervention involved the development of Computer Decision Support Software (CDSS) to help the ED nurses in performing the triage. The training of the triage nurses both in the use of the CDSS and in persuasive patient communication with respect to managing the patient’s expectations took 12 hours.

The triage was conducted in a separate examination room at the ED with the aim of seeing patients within 15 min after their arrival. Only nurses with at least one year of experience in the ED were allowed to triage. The ED nurse performed the triage aided by the CDSS resulting in allocation of the patient to either ED or GPC. During control clusters, the patient was not informed about this advice. During intervention clusters, the patient was allowed to accept or refuse this advice. When accepting the advice to attend the GPC, the patient received a short referral note and instructions to go to the GPC. In case the patient preferred to stay at the ED, the patient was led to a waiting room. When the triage protocol outcome indicated that a patient could be referred to the GPC, the ED nurse was allowed to overrule the outcome of the triage protocol if deemed inappropriate.

The aim of the process evaluation presented in this article is to identify factors that influenced the medical staff during the triage trial, as well as obtaining insight into the facilitators and inhibitors that have surfaced during the trial. Change management research has shown that the adoption of innovation and resistance to change depends on different factors that can be aggregated into three major levels: organisational, group and individual level [27], [28]. On the organizational level, the focus lies mainly on factors such as structure, strategy, and resources and how they facilitate or hinder the planned intervention [27], [28]. The group level encompasses the social interaction between co-workers and other staff members and stakeholders who participate in the intervention [28]. This envelopes both interactions within a group and between groups [27]. On the individual level, literature identifies three sublevels of factors influencing the willingness to adopt innovation and change: the individual's personality, their motivation and their cognitive capabilities [28]. This theoretical framework will serve as guidance for the data collection and analysis of this process evaluation.

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