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Objective To assess the safety and efficiency of triaging low urgent self-referred patients at the emergency department (ED) to a general practitioner (GP) based on the Manchester triage system (MTS). Methods All self-referred patients in the evening, night and weekends were included in this prospective observational study. Patients were triaged by an ED nurse according to the MTS and allocated to a GP or the ED according to a predefined care scheme. For patients treated by the GP, assessments were made of safety as measured by hospitalisation and return to the ED within 2 weeks, and efficiency as measured by referral to the ED. Results In 80% of cases allocation of the self-referrals to the ED or GP was according to a predefined scheme. Of the 3129 low urgent self-referred patients triaged to the GP, 2840 (90.8%) were sent home, 202 (6.5%) were directly referred to the ED, 36 (1.2%) were hospitalised. Within a random sample of low urgent patients sent home by the GP (222 of 2840), 8 (3.6%) returned to the ED within 2 weeks. Against the agreed MTS scheme, the ED also directly treated 664 low urgent patients, mainly for extremity problems (n=512). Despite the care agreements, 227 urgent patients were treated by the GP, with a referral rate to the ED of 18.1%, a hospitalisation rate of 4.0% and a 4.5% return rate to the ED within 2 weeks. Conclusions Low urgent self-referrals, with the exception of extremity problems, were shown to be treated efficiently and safely by a GP. A selected group of more urgent patients also seem to be handled adequately by the GP. Triage of low urgent patients with extremity problems and reasons for nurses not following a predefined triage allocation scheme need further elaboration.

Objective Pain is one of the six general discriminators of the Manchester triage system (MTS). The frequency of pain assessments conducted at triage with the MTS, and patient, nurse and triage characteristics associated with pain assessments were studied. Also, nurses9 reasons for not assessing pain at triage were studied. Methods The study consisted of two parts. In part 1, nurses from two emergency departments (ED) registered patient characteristics and the process of triage for every presenting patient during 1 week in May 2009. The characteristics of triage nurses were registered on a second form. In part 2 of the study, 13 nurses were interviewed about reasons for not assessing pain at triage. Results According to the MTS guidelines, pain assessments should have been conducted in 86.1% of the patient presentations. It was only assessed in 32.2% of these patients. Characteristics associated with conducting pain assessments were children under 12 years of age, patients referred by others than a general practitioner or ambulance service, intake of medication before an ED visit, experience of the nurse with the MTS and the duration of triage. Reasons for not assessing pain according to the guidelines included the thought of triage nurses that pain assessments result in overtriage. Conclusions Pain assessments at triage are conducted infrequently because of insufficient education, conducting activities at triage that are not necessary for estimating urgency and a lack of clarity in the MTS guidelines. Changes in these areas are necessary to improve the reliability and validity of pain assessments and the MTS.

Objectives and Background Measurements of patients9 perceptions have been recognised as an important part of evaluations of the quality of care. However, in the Netherlands a standardised and validated instrument to systematically measure how patients experience the healthcare delivered in an emergency department (ED) is lacking. Therefore, we developed the Consumer Quality Index for the Emergency Department (CQI ED). Methods The CQI ED was developed according to the national CQI guideline. First, qualitative research was used to construct the CQI ED. Second, to assess psychometric characteristics the 84-item CQI ED, temporarily extended with 50 important questions, was sent to 653 patients who attended a large-sized ED in the Netherlands in January 2010. Exploratory factor analyses were used to determine the domains of the questionnaire. Improvement scores were computed by multiplying the importance scores with the percentages to the negative answering categories of the experience questions. Results Survey data of 304 (47%) patients were used for analyses. The first exploratory factor analysis resulted in 15 items grouped in three internally consistent domains: Attitude of the healthcare professionals, environment and impression of the ED and respect and explanation towards the patient. The second analysis, ignoring the general CQI guidelines, included 27 items and resulted in 5 domains: Attitude of the healthcare professionals, information and explanation, environment of the ED, leaving the ED, and general information and rapidity of care. The three most important aspects in healthcare performance at the ED were: trust in the competence of the healthcare professionals, hygiene at the ED and received care as expected. The highest improvement scores were mostly about informing patients. Conclusions The CQI ED is a reliable instrument to measure patients9 experiences with care at the ED and seems applicable for local quality improvement. Preferring a construct of three or five domains depends on the choice for a between-ED or within-ED comparison.