Effects of a Central Point of Assessment with Digitally Assisted Triage in an Integrated Emergency Center

Emergency departments treat a large proportion of patients requiring urgent medical attention. Due to the increasing utilization of these departments by low-urgency cases, they are increasingly becoming overcrowded, which has a negative effect on the care of critically ill and injured patients (1). Health policy measures are aimed at improving synchronization between emergency departments and primary care walk-in clinics in integrated emergency centers (IEC) (2). The key challenge of this coupling is the upstream triage of emergency patients at a central point of assessment (CPA). There are no concepts to date for a single-stage assessment procedure carried out by staff qualified in emergency medicine that also includes the allocation of patients to the appropriate sector.

Methods

In October 2023, an IEC service was implemented by integrating a primary care walk-in clinic from 8:00 am to 11:00 pm as well as an upstream CPA. Self-referring patients (SP) are assessed there by emergency department staff using a digital decision support system based on urgency (Emergency Severity Index [3]) and assigned to a treatment sector (primary care walk-in clinic or emergency department). Only once patients are in the respective treatment sector are they administratively admitted. The effect of the CPA on the emergency department was measured based on the percentage change in monthly patient numbers compared to the respective reference months of October to June in the previous years from 2013 to 2023. A comparison with national emergency department registry data was also carried out (4). In December 2023, a system was established to record secondary transfers from the primary care walk-in clinic to the emergency department and 30-day hospital mortality. All mean values are given as medians with a 95% confidence interval (CI). Outlier values were eliminated using the ROUT method (Q = 1%).

Results

Between October 2023 and June 2024, N = 48 835 patients were treated throughout the entire IEC; n = 33 258 (68.1%) of these were SP. The time to completion of the upstream assessment (door-to-triage time including waiting time) at the CPA was 5.01 minutes (95% confidence interval: [4.96; 5.06]). Of all SP, n = 12 265 (36.9%) were referred to the primary care walk-in clinic. Fewer patients presented to the CPA on weekdays (n = 141.0; [136.0; 148.0] compared to weekends (n = 191.5; [183.0; 211.0]; p < 0.0001). The percentage of SP referred to the primary care walk-in clinic was also lower on weekdays (24.9%; [22.3; 26.8] compared to weekends (38.9%; [36.4; 40.4]; p < 0.0001).

From 2013 to 2023, the average percentage change in monthly patient numbers (October to June; n = 81) was + 4.0% (calculated as 104.0%; [101.8; 107.3]). In the 9 months following implementation of the IEC, the monthly change declined by 7.5% to 96.5% ([94.1; 101.4]; p = 0.0003) of the previous year’s value. This effect can be attributed to the decline in low-urgency patients (ESI 4–5; Figure 1). At the sites participating in the emergency department registry (4), the change compared to the previous year during the observation period was +5.6% (calculated as 105.6%; [100.6; 110.4]), and thus higher than at the study center (–3.5%; calculated as 96.5%; p = 0.0106). There was also an increase in high-urgency cases within the emergency department (ESI 1–2; Figure 2).

Figure 1

Annual change in triage category within the emergency department between 2013 and 2024 (October to June)

Figure 2

Proportion of triage categories within the emergency department between 2013 and 2024 (October to June)

Of the n = 10 540 SPs referred to the primary care walk-in clinic from December 2023, n = 912 (8.7%) were subsequently referred on to the emergency department, from where n = 332 (3.2%) were admitted as inpatients (36.4% of the transfers). Three of these patients died within the first 30 days in hospital (0.03%).

Discussion

The effects of a single-stage assessment at an IEC have been described for the first time (5). A total of 68.1% of all IEC patients were assessed at the CPA and referred onwards. In view of the door-to-triage time of 5.01 min, there was a high level of compliance with the German Joint Federal Committee’s (Gemeinsamer Bundesausschuss, G-BA) target of 10 min. Thanks to the CPA, it was possible to avoid duplicate registrations, which were only necessary in 8.65% of cases when transferring patients from the primary care walk-in center to the emergency department. The upward trend in the number of patients in the emergency department (+4.0% on average since 2013) declined by 7.5% (a decrease from 104.0% to 96.5% of the previous year’s figures), which is largely due to the reduction in ESI 4–5 levels of urgency (79.9% of the previous year’s figures). Accordingly, a higher proportion of high-urgency cases could be treated in the emergency department. The lack of availability of transsectoral data on the outcomes achieved when individuals are discharged as outpatients from either sector is a limiting factor. Of the patients referred by the primary care walk-in clinic to the emergency department, 63.6% were discharged as outpatients. The question of what resources were lacking in the primary care walk-in clinic to prevent referral to the emergency department remains to be investigated. On weekdays, the number of patients at the CPA and the proportion of referrals to the primary care walk-in clinic were lower than on weekends, which speaks against a pull effect for the IEC.

The IEC concept with a CPA operated by the emergency department is effective, fast, and shows the potential to serve as a means to triage emergency patients in an IEC, in line with health policy impetus. Whether this can achieve lasting effects in terms of a reduction in emergency admissions is currently unclear and needs to be evaluated in multicenter follow-up studies.

Felix Patricius Hans, Michael Clemens Röttger, Jan Kleinekort, Matthias Kühn, Leo Benning, Jochen Brich, Dominik Gottlieb, Ferdinand Christian Wagner, Hans-Jörg Busch

University Emergency Center, Medical Center-University of Freiburg, Freiburg, Germany (Hans, Röttger, Kleinekort, Kühn, Benning, Gottlieb, Busch) [e-mail]

Department of Neurology and Clinical Neuroscience, Faculty of Medicine, University of Freiburg, Germany (Brich)

Department of Orthopaedics and Trauma Surgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany (Wagner)

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript submitted on 20 March 2024, revised version accepted 26 September 2024.

Translated from the original German by Christine Rye.

Cite this as
Hans FP, Röttger MC, Kleinekort J, Kühn M, Benning L, Brich J, Gottlieb D, Wagner FC, Busch HJ: Effects of a central point of assessment with digitally assisted triage in an integrated emergency center

Dtsch Arztebl Int 2024; 121: 849–50. DOI: 10.3238/arztebl.m2024.0201

References

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