Introduction

The increase in emergency care requests by the population is a well-known fact.¹ In the year 2022 alone, a 30% increase in the number of people that received emergency care in Spain was estimated with respect to the year 2021.² One of the main reasons for this increase has been the rise in the expectations of the population. Users expect to be treated for any alteration in their state of health almost immediately, and to this end a great amount of resources is required.¹ Previous studies suggest that the population with primary care (PC) difficulties go to the emergency deparment (ED) for this type of care and that between 10% and 60% of the patients in the emergency room could be treated in less urgent care services.^3-5

Another factor contributing to the overcrowding of ED is the change in the profile of users. There has been an increase in the age of treated people, an increase in chronicity, complexity, frailty, and comorbidity, which leads to an increase in complications and adverse reactions to medications.^3-6 This change in user profile has meant that emergency care, traditionally focused only on the clinical process, has had to adopt a social and family perspective.⁶ Therefore, emergency rooms must make organizational changes to improve the quality and efficiency of care and to adapt it to the users‘ profile.

In recent years, initiatives have been developed to strengthen triage, create new care areas, and modify emergency work processes, which have had positive results, although limited to hospital emergency rooms.^7,8 In Andalusia (Spain), a model of emergency care based on integrated and continuous care was adopted, consisting of the hospitals’ emergency services and those of PC centers, as well as the 061 Health Emergency Center.⁹⁾ The Primary Care Emergency Departments (PCED) are located in centers that provide care to the reference population during the closing hours of PC centers (evenings and nights from Monday to Friday, Saturdays, Sundays, and holidays). These services also have mobile teams that provide urgent/emergency care 24 hours a day, providing assisted transfers to referral hospitals when necessary.

To guarantee citizens’ access to the service and to organize healthcare, the PCEDs have incorporated tools such as patient sorting systems at the fixed locations, referral criteria, time-dependent integrated care processes, and clinical process protocols.¹⁰ In addition, as of 2018, nurses with an advanced practice competency profile (APN)^6,11 were incorporated following the competencies recognized for this role in Andalusia.^6,12 Specifically, advanced APNs in nursing consultation have specific competencies regarding patient safety in the emergency room, cultural competence, communication and clinical interview, interpersonal relationship skills, management of specific computer systems in the area, and result orientation.¹²

Basic triage by nurses in the ED has been defined as the Reception, Welcome, and Sorting of patients^13,14 and is based on the Spanish Triage System with five levels of classification, like its predecessors, the Manchester Triage Scale and the Andorran Triage Model.^15,16 Recently, with the boost of APN graduate training, advanced patient sorting or advanced triage is being carried out at the PCEDs, in which APN nurses can refer urgent cases to the reference hospital, offer recommendations and support if the patient has to stay at home, mobilize the corresponding PC team, or resolve the situation immediately and discharge the patient. ⁽⁶ Previous studies in different health systems on the role of APNs or equivalent suggest that they provide better access and reduce waiting times, with similar resource use to that of primary care physicians, including the number of referrals, admissions, revisits and prescriptions, and an even better patient experience.^17-21

Despite these results, the impact of nurse presence in patient triage in the PCEDs has not been specifically analyzed. The analysis of some outcome indicators before and after the inclusion of APN nurses competencies in the PCED triage may provide evidence to support the progress of APN nurses in advanced patient sorting and in managing emergency care demandin PC. The objective of this study was to determine the influence of nurses in sorting patients in the PCED though a comparative study of priorities and discharge referrals in relation to the reasons for consultation, before and after the inclusion of nurses in this process in the PCED of Granada (Andalusia) in Spain.

Methods

A descriptive retrospective study was carried out comparing the emergencies treated in the PCEDs of the Basic Health District of the city of Granada. This district is made up of three PCEDs: La Chana, Zaidín, and Gran Capitán. The areas covered by the different PCEDs are heterogeneous, both in terms of their size and the characteristics of the population they treat; all of them cover city areas and rural localities of the metropolitan area.²²

The data were obtained from DIRAYA URGENCIAS (DIRAYA-U), which is the health information system of the Andalusian Health Service. The data were provided in an anonymized form and subsequently exported to a database created ad hoc for this study. The database was initially refined by excluding incomplete records concerning the study variables. The years 2017 and 2019 were compared. In 2017, patient sorting was done only by the physician, and in 2018 the incorporation of nurses into patient sorting began, a process that lasted several months, being completed and in force in 2019.

The variables analyzed in the assistance requests were: Age (< 14 years, 15-65, and > 65 years); Sex; PCED (La Chana, Zaidín and Gran Capitán); Type of discharge referral (Admission to another center, Voluntary discharge, To home, To specialist, Exitus letalis, Escape, Home hospitalization, Cross-consultation attended, To family physician, To mutual insurance company, Does not attend, Other, Transfer to outpatient care, Transfer to hospital accompanied by medical staff, Transfer to another hospital, Transfer to another service); Priority levels (from I to V) according to the Spanish Triage System; and Reason for consultation (corresponds to the 179 symptoms predetermined in the DIRAYA-U system). To facilitate the analysis, the reasons for consultation were grouped according to ICD-9 coding, although some were treated independently because they fall into various categories of this classification system. For the comparative analysis, only discharges to home, referrals to the family physician, or hospital transfers were considered, since together they accounted for 98.6% and 98.9% of cases in the respective years of study.

The variables level of priority and type of discharge referral and their relationship with the reasons for consultation can be considered indicators of nursing care activity in the sorting and management of care requests. Regarding data analysis, the variables were described by calculating frequency and percentage. To compare the two study years, the Chi-square test or Fisher’s exact test were used for categorical variables, whichever was appropriate. A statistical significance level of 0.05 was considered. The analysis was performed with IBM’s SPSS© v.26 software.

This study was approved by the Andalusian Research Ethics Committee on January 11, 2021, with code EPA_SUAP.

Results

The number of emergency care requests was 418,528 in 2017 and 460,304 in 2019. After excluding incomplete records, 41295 records were analyzed, 18,663 (45.19%) in 2017 and 22,632 (54.80%) in 2019 (Figure 1).

Figure 1 Study scheme 

Regarding the characteristics of the analyzed records in both years, an increase of patients in the age range between 15-65 years (p<0.001), in the percentage of female patients (p=0.004), and in patients being cared for at the PCED La Chana (p<0.001) in 2019 with respect to 2017 was observed (Table 1).

Some of the reasons for consultation have changed percentagewise in 2019 compared to 2017. Noteworthy is the increase in the percentage in 2019 of cases of diseases of the genitourinary system (p<0.001) and of malaise (p<0.001), and the decrease in the percentage of mental, neurobehavioral, and neurodevelopmental disorders (p=0.029), diseases of the circulatory system (p=0.024), and fever (p<0.001) (Table 2).

Regarding the priorities identified in triage, there was a notable increase in the percentage of emergencies identified as priorities IV (p<0.001) and a significant decrease in priorities V (p<0.001), showing a more distributed allocation of these priorities in 2019 than in 2017.

The detailed analysis of the relation between priorities and the reasons for consultation showed that, in 2019, there was an increase in cases of malaise classified as Priority II (p=0.002), and in cases of diseases of the circulatory system (p<0.001), dyspnea (p<0.001), malaise (p<0.001), and headache (p<0.001) classified as Priority III.

Cases of disorders of the eye and adnexa (p=0.031), of diseases of the skin and subcutaneous tissue (p<0.001), of diseases of the genitourinary system (p<0.001), and of those characterized as malaise (p<0.001) classified as Priority IV also increased. Finally, the percentage of cases of diseases of the skin and subcutaneous tissue (p<0.001), of diseases of the genitourinary system (p<0.001), and of malaise (p<0.001), classified as Priority V also increased in 2019 (Table 3).

Regarding total referrals, home referrals decreased percentagewise in 2019 in comparison to 2017 (p<0.001), while family physician referrals increased (p<0.001). The detailed referral analysis regarding each of the priorities shows that, in 2019, for Priority III, hospital referrals (p=0.002) and home discharges (p<0.001) increased, while family physician referrals decreased (p<0.001). As for Priority V, the home referral percentage increased in 2019 (81.1%, p=0.003), while family physician referrals decreased (p=0.011) (Table 4).

Detailed referral analysis according to the reasons for consultation showed that in 2019 hospital, home, and family physician referrals increased for those patients who went to the emergency room due to malaise; these referrals decreased for patients with fever. Those patients with skin and subcutaneous tissue diseases and genitourinary diseases were discharged to home in a higher percentage in 2019 (p=0.008 y p<0.001, respectively), and patients with genitourinary diseases were referred to family physicians in a higher percentage in 2019 (Table 5).

Discussion

In this study, we aimed to determine the influence of nurses when sorting patients in the PCED of Granada by means of a comparative analysis of the levels of priority assigned and discharge referrals regarding the reasons for consultation, before (in 2017) and after the inclusion of nurses in the process (in 2019). In the current international scenario, the roles played by healthcare professionals in primary care are being revised. On this matter, this study provides knowledge for proposing a hypothesis on the role nurses could play in emergency care within primary care.

The first surprising result was the high number of incomplete records in the DIRAYA-U system, which hampered the analysis of over 55% of the records from 2017 and over 45% from 2019. There is abundant literature on the quality of data and the problems in implementing digital records in emergency rooms, in which staff express that there are several problems in completing them, such as staff rotation, pressure to provide care, or excessive bureaucracy.^23,24 Other highlighted problems are related to the complex structure of systems intended for the standardization of data (e.g., drop-down menus or restrictions in text input), which can lead to problems caused by system design.²⁵ However, it is necessary to point out that in 2019 the percentage of completed records improved noticeably. This can be explained by the inclusion of nurses in the triage record system and the implementation of the PCED. A recent study showed that nurses complete digital records more easily and feel more satisfaction when using them, regarding their collaborative aspects, than doctors, especially in primary care.²⁶

Likewise, we found that, when compared to the standard patient sorting management in PCEDs, involving nurses in the process produced significant changes in the allocation of Priorities III, IV, and V, and in discharge referrals to home and to the family physician. We have found that the involvement of nurses has improved the assignment of priority levels in patient care, especially at low complexity levels. This is a result consistent with the innovation that resulted from nurse participation in improving the patient sorting system and broadening he perspective on the emergency itself, which entails including the perspective of care.^12,27 This means that, along with seriousness, aspects such as complexity or frailty are considered in the requests of patients, making it possible to distinguish more clearly those problems of lesser clinical concern.^12,28 Previous studies have pointed out the excellent quality of the care provided by these professionals, highlighting that the comprehensive emergency care they provide is safe and effective, patient-centered, timely, and efficient.^20,29

Discharge decisions, however, seem to have been more poorly resolved with the intervention of nurses, since, overall, there were fewer in situ cases discharged to home and an increase in family physician referrals. However, the analysis of the relationship between Priorities and discharge referrals shows that in Priorities III and V, with nurse intervention, a significantly higher percentage of in situ cases was resolved with home discharge and a lower percentage of family physician referrals. This is consistent with the competencies described in emergency nurse consultation for low-complexity situations.⁶ Several studies reported that nurses, with appropriate training, can manage low-complexity acute health problems with a quality of care comparable to that of general physicians in terms of problem resolution.^18,27) Some authors recommend being cautious with this type of results and increasing research when the role of the nurse in triage is not consolidated,^27,30 or when there is diversity in the training and experience of the nurses.^31,32 It should also be pointed out that in Priority V there was an increase in home referrals, which is relevant since, in addition to improving patient care, it also makes it more adequate and reduces the use of resources.

The analysis of the reasons for consultation in relation to priorities and discharge referrals showed that, compared to standard care, nurse intervention resulted in significant variations in the level of priority assignment of relatively emergent emergency or non-emergent situations (Priority III, IV, and V), as foreseen in the reference document.⁶ Few studies address this perspective and this issue. The literature review by Laurant et al.,²⁰ which includes emergency care in PC, although it does not analyze it specifically, suggests that nurse-delivered care, compared to physician-delivered care (in PC), probably results in similar or better health outcomes for a wide range of patient conditions with a low to moderate level of evidence of certainty. Jennings et al.,³³ who analyzed the care provided by emergency nurses, found that the most common referrals were to home and to the family physician, consistent with our results. In their research they point out that emergency nurses practice a truly hybrid model of service delivery, having both medical and nursing skills with an emphasis on health promotion, education, and comprehensive care.

Consistent with this argument, we consider that the results of the indicators analyzed before and after the nurse intervention in patient sorting in the PCEDs offer some evidence that nurses can be autonomous when administering patient care and resolving minor clinical problems, following the concept of nurse patient request management and the role of the APN,³⁴⁾ who, under an agreed protocol and within their scope of competence, carries out advanced patient sorting while managing emergency requests in PC. However, further studies are needed to confirm and broaden these results. It also remains to be determined whether the competencies of the triage nurse in the PCED are developed similarly during periods of high patient visitation.

This study has limitations in generalizing its results since it is an observational retrospective study of one health district and three PCED units. Likewise, it was not possible to control for other variables that may have influenced priority classification and discharge referral, which may not depend on the presence of nurses in the triage process.

We can conclude from this study that these findings provide evidence of the role that nurses can play in emergency care in PC services concerning triage. The involvement of these professionals has been related to the determination of priorities, discharge referrals, and management of the reasons for consultation. This shows that these professionals may have some autonomy in patient care and in the resolution of minor problems in PC emergency settings.