Nurse management of low complexity problems in primary care emergency departments: A non randomised controlled trial

doi:10.21203/rs.3.rs-4685936/v1

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Research Article

Nurse management of low complexity problems in primary care emergency departments: A non randomised controlled trial

https://doi.org/10.21203/rs.3.rs-4685936/v1

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Background

Health systems must implement strategies to adapt to the social changes caused by high demand in primary care. Since 2009, the Catalan Institute of Health has been expanding the Nursing Management of Demand programme through which nursing autonomously addresses low-complexity health problems. This study aims to analyse whether this programme is a factor in improving the efficiency and quality of care in a primary care emergency centre.

Method: non-randomized controlled experimental study that contrasted the implementation of the programme applied to an experimental group treated by nursing versus a control group treated by medicine. The study was approved on 14 July 2022 by the Research Ethics Committee of the Jordi Gol University Institute following the guidelines of the TREND declaration.

Results: A total of 312 patients were included in the study, all of whom came to the emergency centre with five types of low-complexity health problems. 156 were attended by nursing and 156 were attended by medicine. The experimental group were seen in 15.1 minutes and the control group in 33.25 minutes. There was no significant difference in the assessment of the quality of care received and there were no differences in the number of consultations for the same problem. Prescription by nurses was lower, with an average of 1.79 medicines per participant versus 2.26 medicines prescribed by doctors.

Conclusion: The results of the study suggest that Nursing Management of Demand was a factor in improving the efficiency and quality of care in the emergency centre. Nursing resolution capacity, after applying algorithms, offered quality care, with fewer medicine prescriptions and good patient satisfaction without increasing the number of consultations due to the same problem.

Trial registration: The protocol of the current study was registered at Clinicaltrials.gov, with identification NCT06298240.

Demographic and technological changes, the aging of the population, as well as their health expectations, are common social elements in many countries that determine how citizens experience everything related to health and the processes of getting ill, thereby affecting how primary care (PC) services are used. Furthermore, we must not forget other characteristics of society today, such as the prevailing consumerist culture and the medicalization of health, which influence the frequency of consultations (1). This reality requires that healthcare models shift the weight of care from the hospital setting to the community setting (2, 3).

According to the primary health care activity monitoring programme Primary Health Care Activity Monitor for Europe (PHAMEU), funded by the European Commission and operating in 31 countries, PC is currently facing challenges, regardless of the delivery model, derived from a change in demand by the population, a change in the supply of care and changes in the financial and technological context (4).

On the other hand, the global economic situation forces governments to reformulate the financing of health services that are under pressure, mainly due to socio-demographic changes. Among the reasons for the increased pressure on health services are the high rates of frequent visits to PC. This is a phenomenon that has been covered by diverse literature from the last two decades (5, 6) and which was conceptualized as a small subgroup of patients who consume most primary care services (7).

Emergency care in PC is a challenge in all health systems. In the United States, it represents 30% of 1.2 billion outpatient consultations (8). This increasing rate of consultations produces a high cost for public health systems, and a considerable workload and much frustration for general practitioners (9). The researchers carried out a transversal study, based on 3,815 interviews with patients from 77 primary care centres in Catalonia, Spain, in which they linked attendance with factors such as having sick leave, reporting mental health problems, arthritis/rheumatism or bronchitis, among others. On the other hand, and according to the review of 61 articles, mostly from the United Kingdom, the United States and Scandinavia, carried out by Vedsted and Christensen (10), 10% of the most frequent patients represented between 30% and 50% of all consultations.

The pressure of visits in primary care has required the reorganization of health professionals and their roles. In this global challenge, the role of nursing and the improvement of its training is becoming a valid tool in dealing with the field of acute health problems of low complexity. However, international differences in the training of nurses make it difficult to standardize care models due to a disparity in their competencies. In the United States, their advanced training and autonomous role manage to control quality chronic care for patients with pathologies such as diabetes, hypertension, arthritis or asthma, thereby achieving a reduction in the rate of hospital admissions (11). Of note is the fact there is no data to suggest that nursing professionals in states that impose greater restrictions on their competencies provide safer and better care than those in less restrictive states (12). The author affirms that eighteen US states have liberalized and standardized legislation to expand independent practice and prescribing by nurses. On the other hand, and added to the capacity for nursing to address patients' health problems, it is necessary to take into account the international evolution of prescribing medicines. Today, nurses can legally prescribe medications in quite a few countries, in some cases under specific circumstances; examples include Australia, Canada, Finland, Ireland, New Zealand, Norway, South Africa, Sweden, the Netherlands, the United Kingdom, and the United States (13).

In recent decades, several studies have compared the health care of doctors with that of nurses. A meta-analysis looked at care provided by nurses or midwives in primary care settings in the United States and Canada, with that provided by physicians. The results showed that the care provided by nurses achieved better treatment adherence and satisfaction (14). Along the same lines, a more recent systematic review (15) indicated that nurses' care was comparable to that of doctors, but also that nurses obtained better levels of satisfaction and spent more time on seeing patients.

The latest published systematic review by Laurant et al. (3) identified 18 randomized trials that showed that for some persistent physical ailments and chronic diseases, trained nurses provide quality care, equal to or even better than that offered by primary care practitioners, and they may even achieve better health outcomes.

In Spain, a four-year university degree is required to practice as a nurse, sufficient training to be able to autonomously and safely address patient care with low-complexity acute illnesses (16). Regarding the ability of Spanish nurses to prescribe medications, the regional and national legal framework has developed with special significance since 2015. Royal Decree 1302/2018 reoriented the state legal framework for the indication, use and authorization of dispensing by nurses with respect to certain medications subject to medical prescription through a marked collaborative nature and with the aim of trying to guarantee continuity of care and safety of any patient, and, on the other hand, modifying and expanding the requirements demanded of nursing to be able to prescribe.

In Catalonia, the Department of Health promoted several measures in seeking to improve the health system in 2009. The Primary Care and Community Health Innovation Plan involved a reorganization of PC (17). The objective was to improve economic sustainability and address the growing demand of patients by referring them to the professional who could provide the best response from their area of expertise (18). At the same time, the opening of primary care emergency centres (Centros de Urgencias de Atención Primaria, hereinafter CUAP) began, designed to address health problems of low and medium complexity, open 24 hours a day, 365 days a year, and which provide support to both PC and hospital emergency services.

In 2009 and within this context of healthcare reorganization in Catalonia, the Nursing Management of Demand (Gestión Enfermera de la Demanda, hereinafter GED) concept was born (19), a programme led by PC nursing to address low-complexity health problems. This programme was based on consensual protocols according to scientific evidence, in which the nurse can resolve this demand without the intervention of the doctor and within their sphere of competence.

In Catalonia, and to our knowledge, there is only one randomized trial that compares the effectiveness of care provided by nurses with the usual care provided by general practitioners. In that study, the nurses demonstrated a capacity for resolution, with success in 86% of the cases and no differences were observed in the resolution of symptoms or satisfaction of patients between groups (20). This study was carried out before the implementation of the GED.

Thanks to the results of the implementation of the GED and the public satisfaction rates, currently 30 paediatric and 36 adult protocols are active in the computerized clinical history software programme (Estación Clínica de Atención Primaria, hereinafter ECAP) of the Catalan Institute of Health.

In the Catalan area, the literature offers results from various transversal studies that agree on the ability of Catalan nurses to solve low-complexity health problems. The most current is Fernández Molero et al. (21). Another extensive multi-centre retrospective work that included data from medical records between 2019 and 2020 and in which 392 primary care areas of the Catalan Institute of Health participated. In this case, the GED protocols were fully in force and minor health problems resolved by nursing came to 50.9% of adult patients and 55.4% of paediatric patients. However, one of the limitations of this study, which the authors recognized, was not recording the rate of other consultations afterwards for the same reasons. This is a variable that we consider a key piece to evaluate the resolution capacity of the GED. The longitudinal study with a 3-year follow-up carried out by Jurado-Campos et al. (22) showed that resolved cases increased and the number of other consultations afterwards decreased, concluding that nursing capacity to manage the demands of patients without an appointment improved following an interdisciplinary intervention using a mutually agreed upon and locally adapted approach.

The objective of this study was to determine if the implementation of the GED in a CUAP improved the efficiency and quality of care.

The Primary Care Emergency Centre (CUAP) covers 270,000 inhabitants of the Maresme region, province of Barcelona, Catalonia (Spain) (23). The CUAP is located in the municipality of Mataró and was put into operation in May 2021. Since its opening, it has seen more than 100,000 patients, with it being considered a key piece within the territory's health system. Its management depends on the Catalan Institute of Health. Potential participants for this study were patients assigned to the demographic area of influence of the health centre.

The protocol for the study was registered in the CinicalTrials.gov (CT) clinical trials database of the US National Library of Medicine (NIH) with registration number NCT06298240.

2.1. Design and participants

A non-randomized controlled experimental study was developed, following the TREND guidelines (24), (Supplementary Material 1), carried out in a CUAP, where the GED procedure was applied. This procedure was carried out by volunteer nurses for this study and who during their working hours cared for patients at the centre, applying the GED. Before the start of the study, professionals were trained in two training sessions on the five health problems accepted for this study. They also had access to the corresponding algorithms in the patient clinical course computer programme ECAP.

The inclusion criteria for the study were:

1. Presenting any of the following health problems:

Non-complex airway issues (rhinopharyngitis or common cold, pharyngitis, tonsillitis or respiratory virus)
Urinary problems (cystitis or urinary tract infection, only in women)
Acute skin lesions (burns or acute wounds)
Toothache
Gastrointestinal disorders

Being between 18 and 65 years old

Go to the CUAP between October 2022 and February 2024.

Sign the written informed consent

An exclusion criterion was to present a screening with a complexity of less than 3, according to the Andorran screening model (MAT) (25) integrated into the Catalan emergency plan (26). Complexity screening is first carried out on all patients who attend the CUAP. Nursing applies and assigns the patient a priority level for urgent care. Grades less than 3 are assigned to foreseeable life-threatening situations (level 2), or situations requiring immediate life-threatening resuscitation (level 1).

A sample size of 156 participants in each group (n = 312) was estimated to be necessary to detect as statistically significant a difference of 20% in the percentage of people who wait less than 15 minutes to be seen than was expected in 50% of the control group. An alpha risk of 0.05 and a beta risk of 0.1 in a bilateral contrast were accepted for this estimation.

2.2. Assignment

The assignment to the groups was made based on the fortnight of the month in which they attended the CUAP. Patients who were seen during the first 15 working days of the study months between 10 a.m. and 8 p.m. were assigned to the experimental group, in which the GED intervention was applied. The participants in the control group, treated with the usual medical procedures, were assigned during the second fortnight of the study months at the same time and on the same work days. The reason for carrying out this assignment was to avoid cross contamination or interference between the two groups.

The variables needed for the study were taken on the same day of the visit and one month after it. On the same day, the time of arrival at the CUAP, time of starting the consultation and time of departure, and degree of satisfaction were collected from the patient's computerized medical history through a survey. One month later, data related to possible consultations for the same reason, number of prescribed drugs, need to request time off work, and assessment of overall satisfaction with the entire process were extracted through a telephone survey.

The data was entered into the Research Electronic Data Capture REDCap® management platform (27, 28), in a questionnaire created exclusively for this study. This data was recorded on the same day of the consultation and after the telephone satisfaction survey.

2.3. Flows and recruitment

Once the CUAP patients were classified according to their complexity and MAT care screening, the nursing staff informed them of the study and the possibility of participating. A total of 312 patients signed the informed consent, of which 156 participants were assigned to the experimental group (intervention) and who attended the CUAP in the first 15 days of the month and 156 were assigned to the control group (without intervention) between day 16 and the last day of the month. At the end of the nursing or medical visit, the participant answered a brief quality survey and between 15 days and one month later, they received a second telephone satisfaction survey (see Fig. 1).

2.4. Analysis of data

Univariate analysis was performed with mean and standard deviation for quantitative variables and frequency and percentage for qualitative variables. Socio-demographic and clinical variables were compared with Student's t-test and Chi square to evaluate the comparability of the study groups. The outcome variables waiting times and those related to patient satisfaction were compared with Student's t-test. Finally, the percentage of waiting time less than 15 minutes in the two study groups was calculated. The normality of the variables was checked with Kolmogorov Smirnov. All contrasts were made with an alpha of 0.05. The SPP v.26 statistical package was used (29).

2.5. Ethical considerations

The study was approved on 14 July 2022 by the Drug Research Ethics Committee of the Jordi Gol University Institute for Research in Primary Health Care (IDIAPJGol). The data processing was carried out in compliance with Regulation (EU) 2016/679 of the European Parliament and the Council, of 27 April 2016, regarding the protection of natural persons with respect to the processing of personal data and free circulation of this data (GDPR), and Organic Law 3/2018, on data protection and guarantee of digital rights.

3.1. Description of the sample and comparison of the groups

Between October 2022 and February 2024, a total of 312 patients were recruited. There were 172 (55.1%) women. The average age of the participants was 32.73 years (SD 12.48). In the experimental group, 0.6% were assigned a MAT screening priority value of 3, 61.3% with value 4 and 38.1% with value 5. In the control group, no participants were assigned with MAT 3, 69.2% with a value of 4 and 30.8% with a value of 5.

The main reason for being seen was upper respiratory tract problems, with 215 cases treated (68.9%), followed by gastrointestinal disorders, 52 cases (16.7%), toothache with 26 cases (8.3%) and urinary problems in 19 cases (6.1%). No injury cases were seen. Table 1 shows in detail the comparison of the socio-demographic and clinical variables of the experimental and control groups. The results indicate that there are no significant differences between them (p < 0.05), except in the history of hypertension, which was more represented in the control group

(Table 1).

Table 1

Comparison of socio-demographic and clinical variables between the two study groups.
	M (SD)		t	P
	Experimental	Control
Age	31.32 (11.5)	34.06 (13.1)	-1.913	0.057
Number of prescribed medicines	3 (2.73)	2.62 (2.47)	0.643	0.522
	N (/%)		X²	P
MAT Screening			2.960	0.228
3	1 (0.6)	0
4	95 (61.3)	108 (69.2)
5	59 (38.1)	48 (30.8)
Gender			1.950	0.172
Female	91 (59.5)	81 (51.6)
Male	62 (40.5)	76 (48.4)
Reason for consultation
Upper airways	94 (60.6)	110 (70.1)	3.057	0.096
Gastrointestinal disorders	25 (16.1)	24 (15.3)	0.042	0.877
Toothache	14 (9 − 0)	12 (7.6)	0.197	0.687
Urinary problems	12 (7.7)	6 (3.8)	2.205	0.153
Medical history
Diabetes	2 (1.3)	4 (2.5)	0.654	0.684
Hypertension	3 (1.9)	13 (8.3)	6.454	0.018
Prostate pathology	1 (0.6)	0	1.016	0.497
COPD	0	4 (2.5)	4.00	0.063
Asthma	4 (2.6)	9 (5.7)	1.940	0.257
Heart failure	0	1 (0.6)	0.990	1.00
Kidney failure	0	1 (0.6)	0.990	1.000
Obesity	12 (7.7)	8 (5.1)	0.911	0.365
Neoplasia	1 (0.6)	4 (2.5)	1.791	0.371
Depression	2 (1.3)	5 (3.2)	1.276	0.448

3.2. Impact of the intervention on waiting times

As explained in the method section, two different time fractions were collected. The first, the time elapsed from the patient going to the centre and being seen, and the second, the time elapsed from the patient going to the centre and being discharged. In the experimental group the time elapsed until being seen was 15.1 minutes (SD 18.42) and in the control group it was 33.25 minutes (SD 34.11). Nursing completed care in an average of 16.46 minutes and doctors in 13.69 minutes. The total time spent in the centre, that is, from the time the patient arrives until the patient is discharged, was 29.19 minutes (SD 22.05) in the experimental group and 46.73 minutes (SD 35.35) in the control group. From these results, in all reasons for consultation, the waiting time and the overall time until discharge were higher for the control group with significant differences in all cases, except the waiting time for being seen for gastrointestinal reasons. The comparison of the waiting times, for the consultation or the total time spent in the health centre according to the reasons for the visit, is described in Table 2.

The percentages of participants who waited less than 15 minutes to be served were calculated. In the experimental group there were 107 people, which represents 69% of the group. In the control group there were 54, equivalent to 34.4% of the group. As such, there was an increase of 34.6% of patients who waited less than the 15 minutes to be seen in the experimental group. The average attendance time was 13.95 minutes (SD 14.42). In the experimental group the average was 14.47 minutes (SD 17.47) and in the control group, 13.42 minutes (SD 10.49). These time differences were not significant (p = 0.562).

Table 2

Comparison of waiting times according to reason for being seen.
	Time until seen					Total time in centre
	Total (N = 312)	Experimental (n = 155)	Control (157)	t	p	Total (N = 312)	Experimental (n = 155)	Control (157)	t	p
Upper airways	24.432 (28.25)	15.8 (18.38)	32.08 (32.96)	-4.53	< 0.001	37.61 (29.98)	29.23 (21.99)	45.04 (34.01)	-4.093	< 0.001
Gastrointestinal disorders	26.09 (32.25)	18.22 (23.92)	34.60 (38.03)	-1.842	0.073	40.38 (32.68)	31.30 (23.29)	50.20 (38.57)	-2.119	0.041
Toothache	24.77 (33.64)	7.71 (6.8)	44.66 (41.41)	-3.056	0.010	41.19 (36.69)	26.07 (18.68)	58.83 (44.90)	-2.496	0.020
Urinary problems	13.47 (13.99)	7.153 (5.8)	27.16 (27.18)	-2.780	0.001	31.79 (25.82)	27.92 (25.15)	40.17 (27.54)	-0.959	0.351

3.3. Patient experience

The patient experience was measured at two moments. The first, immediately after discharge, where the global assessment concerning the attention received was 9.56 (SD 0.979) on a scale from 0 to 10. In the experimental group it was 9.81 (SD 0.71) and in the control group it was 9.33 (SD 1.14), this difference being statistically significant (p < 0.001). The second, one month after the visit, the same global assessment measurement was carried out concerning the care received by means of a telephone survey. Using this measure, the score obtained by the sample was 8.75 (SD 1.55). The experimental group obtained a score of 8.8 (SD 1.6) and the control group 8.6 (SD 1.4), with this not being a statistically significant difference.

In this second measure, seven specific aspects of care were also evaluated, shown in detail in Table 3. Six of the seven aspects evaluated showed no differences in the scores received by the two groups. Differences were shown in the last question which referred to whether the participant perceived that they would have been better served by another professional. In this case, the control group responded more affirmatively than the experimental group.

Table 3

Patient experience one month after being seen.
	Total (n = 179)	Experimental (n = 97)	Control (n = 82)
	M (SD)			t	p
Global evaluation after 1 month	8.75 (1.55)	8.8 (1.6)	8.6 (1.4)	0.472	0.637
Flexibility of the consultation	7.94 (2.05)	8.19 (1.97)	7.65 (2.12)	1.734	0.085
Professionalism	9.14 (1.2)	9.16 (1.25)	9.11 (1.19)	0.244	0.808
Effectiveness of treatment	8.57 (2.06)	8.52 (2.09)	8.62 (2.03)	0.966	0.754
Health advice	8.95 (1.622)	8.87 (1.63)	9.06 (1.65)	0.607	0.470
	n(%)			Chi-square
Needed another consultation for the same reason	28 (15.6)	17 (17.5)	11 (13.4)	0.569	0.538
The treatment was effective	148 (82.9)	82 (84.5)	66 (80.48)	0.313	0.651
Considers that the consultation would have been more effective if it was carried out by another health professional	54 (30.17)	15 (15.4)	38 (46.34)	26.85	< 0.001

3.4. Consultations for the same reason, incapacity for work and prescribed drugs

Subsequent consultations for the same reason, in the same CUAP or in a PC centre or hospital emergency room in the healthcare influence area, were extracted from the ECAP computerized platform. A total of 41 patients were seen again, 13% of the total sample. This was 21 patients (13.46%) from the control group and 20 (12.82%) from the experimental group, a non-significant difference. Of the participants who were seen again, only 7% of the total required a change in diagnosis, a new pharmacological prescription or additional tests, 10 patients in the control group (6.41%) and 12 patients in the experimental group (7.6%), a non-significant difference. A total of 89 work disabilities were processed, assigned to 28.52% of the total sample. In the control group there were 46 work disabilities (29.48%) and 43 (27.56%) in the experimental group, without statistical significance. In the experimental group, an average of 1.79 medicines were prescribed in 279 prescriptions. In the control group, an average of 2.26 drugs were prescribed in 353 prescriptions. This difference being statistically significant (p < 0.001).

The objective of this study was to determine if the implementation of the GED in a CUAP improved the efficiency and quality of care. The criteria used for the evaluation were waiting times, health care time, patient satisfaction and the consultation rate afterwards for the same reason.

This study focused on the care of low-complexity patients, so only those who were assigned a priority level higher than 3 during the triage stage were selected. In the present study, consultations made by nurses and doctors were of similar complexity. Various literature confirms the ability of nurses to care for patients with low-complexity health problems or minor problems, demonstrating a high level of care, similar to that of general practitioners. These are the conclusions of the randomized studies by Kinnersley et al. (30) and Shum et al. (31), which are confirmed in the studies carried out in Catalonia by Fabrellas et al. (32) and Iglesias et al. (20).

In relation to the reasons for consultation selected for our study, it is worth mentioning that during the recruitment period they added up to a prevalence of 21.86%. Upper respiratory tract problems were the most prevalent (acute laryngitis, upper respiratory tract infections, pharyngeal pain or acute pharyngitis, cough, acute streptococcal tonsillitis, tonsillitis, rhinopharyngitis, viral infection and COVID), with a rate of 11.93%. In second place, urinary problems (acute cystitis without haematuria or urinary tract infection) with 3.21%; in third place, gastrointestinal disorders (vomiting, diarrhoea or gastroenteritis and infectious or non-infectious colitis) 2.30%; and finally, toothache 0.77%. This prevalence data shows the impact of low-complexity health problems on acute demand in PC and leads to reflection on the importance of reinforcing health education as a measure to reduce demand (33). Following this line of discussion, addressing hyper-frequency and care pressure in PC is the task of all professionals, and necessarily implies adapting tasks to different professional profiles. In this sense, care for frequent problems with low clinical risk, preventive activity and control of chronic processes can be taken of by nursing (34).

Regarding the specific results of the four reasons for being seen that were finally recruited, upper respiratory tract problems were in the majority for the entire sample with 68.9%. This result is related to the winter months and the flu and COVID peaks of 2022 and 2023 and which, like other years, activated the usual mechanisms contemplated in the “Comprehensive Emergency Plan of Catalonia” (Plan Integral de Urgencias de Catalunya, PIUC) to address these periods of greater demand due to respiratory pathologies. Gastrointestinal disorders accounted for 16.7%, toothache for 8.3%, and urinary problems for 6.1%. As far as wounds are concerned and which were contemplated in the initial project of the study, they were not used as it is well understood in our emergency centre that they are consultations that nursing cares for autonomously (simple sutures or care of non-complex acute wounds) and which are generally addressed by medicine when there is a complication such as a fracture, functional loss, neuromuscular or venous-arterial issues, cellulitis, etc. Given this, and in order not to interfere with the usual dynamics of the centre, we decided to not use them in this study.

In relation to the time dedicated to the visit, although we detected that nursing dedicated an average of 65 seconds more to the visit than their medical colleagues, the results indicate that there is no statistical difference between both professionals. It is true that some studies have found that the time invested by nurses in consultations is greater than that invested by doctors. Furthermore, this extra time is perceived by patients as an increase in the quality of care (31, 35). At the same time, the review by Karimi-Shahanjarini et al. (36) detected, in the majority of the 69 studies analysed, that patients thought that nursing professionals were more accessible than doctors. For their part, doctors and nurses considered that this substitution, with a collaborative attitude, increased the quality and continuity of patient care.

However, the fact that the nursing time invested in solving low-complexity health problems is similar to that used in the usual interventions, until now, by doctors, would imply that the care carried out by nurses would not mean an increase in resources due to the fact that it is carried out by another professional. This leads us to reflect on the potential of implementing a fixed GED consultation in the future, as an objective to improve patient care, better distributing the medical and nursing care burdens.

The results of the study in relation to the efficiency of the GED, based on the waiting time criterion, show that in the consultations made by nurses the delay in being seen decreased for all reasons for the consultations taking place. Nursing showed a clear difference with their medical colleagues regarding the wait for patients before seen. The experimental group reported more shorter wait times for their patients, with 69% who waited less than 15 minutes to be seen, compared to 34.4% of the control group, treated by doctors. Therefore, an increase of 34.6% was found for the GED consultation.

In the second evaluation criterion, related to the quality of care based on the frequency of consultations for the same health problem in the subsequent 15 days, we analysed whether the treatments proposed by nurses and doctors were effective. To do this, we reviewed the computerized clinical records of all participants. Some 13% of the total sample visited again for the same reason. In this review we see similar quality results in both groups. A proportion of 12.82% of GED patients visited for the same reason, and of these, only 7.6% required a modification of treatment, prescription or request for new tests. In the control group, the percentage of consultations for the same reason was 13.46%; of these, only 6.41% required changes with respect to the initial visit. In line with these results, we find those of the study carried out by Fabrellas et al. (32) that also detected low rates of return of patients from a nursing management programme for same-day consultation, with 16 reasons for adults and 7 in paediatrics, with a rate of 3% in adult patients seen for back pain, nosebleeds, skin lesions and burns and 2% in paediatrics, seen for skin lesions and burns.

Some 53% of the visits made for the same reason did not imply a change in diagnosis or relevant medicines compared to the first visit in either group. This result invites us to reflect on the social change that citizens are experiencing in their way of facing the process of getting sick and the use of health services. On the one hand, the consumerist and immediacy culture of today's society reinforces the overmedicalization of mild acute pathologies or situations of personal or work discomfort, etc. On the other hand, the socio-health reality which is characterized by an increase in the prevalence of comorbidity and fragility, linked to aging, with more informed patients, who want to participate in the decisions that affect their health, in an increasingly digitalized society (37). The care of patients in primary care consultations is a multi-causal phenomenon influenced by the social environment, health organizations and professionals (1). Healthcare organizations and their professionals must face these new challenges with more cohesive teams and new professional profiles.

Understanding the patient's experience during the health care they receive, known as the patient journey (38), allows for the optimization of care processes and the detection of points that negatively impact their experience, and understanding their needs, demands and real concerns. To obtain greater precision of this experience, the participants were surveyed on the same day of the visit, and also a month later. In the survey on the same day of the visit, participant satisfaction was higher in the group treated by nursing (9.81) than in the group treated by medicine (9.33). The most plausible explanation for this result is linked to a shorter waiting time between the complexity screening stage and being seen, compared to the consultation with a doctor, where the wait was longer. On the other hand, the survey carried out 30 days after the visit shows that there are no differences in satisfaction between the two groups. Two possible explanations for this change, produced by the passage of time, we believe may be, on the one hand, that the patient may have a clearer perspective 30 days after the visit, once the entire global process of the health problem has been completed; but, also, memory decreases after several weeks. There is little evidence on the effects of memory over long periods, but it can be expected that it decreases over time and that respondents remember less after several weeks or months, as suggested by the work of Rettig et al. (39). To reduce possible recall biases, at the time of the survey carried out one month after the visit, the patient was informed of details such as the date and time of the visit, the signing of the consent, the first quality survey answered, the reason for the consultation, the medication prescribed and whether there was any subsequent visit for the same reason in the clinical record. In this way, an attempt was made to refresh the patient's memory in order to obtain a higher quality response. In this second survey, seven specific aspects of care were evaluated, looking for the strengths and weaknesses of the patient experience. The ratings of six of the seven points were not different in the two groups, as shown in Table 3. However, the last aspect explored shows an unexpected result. To the question about whether the patients considered that the visit would have been more effective if it had been carried out by another health professional, 15.4% of the group seen by nursing responded that they believed that a doctor would have cared for them better; versus 46.34% of the group seen by doctors who considered that a nurse would have treated them as well as a doctor. This makes us think that patients are increasingly accepting nursing's ability to treat minor health problems with quality. Along these lines, a multi-centre randomized controlled trial is cited that evaluated the acceptability and safety of a nurse-led minor illness service in the United Kingdom (40) where patients agreed with our study in being more satisfied in terms of quality in consultations with nurses, but where the clinical results did not find differences with respect to nursing and medicine.

Regarding prescription by nursing, the results obtained indicate that patients maintained a perception of quality during the consultation or had a similar number of subsequent consultations for the same reasons as their medical colleagues, but with a lower number of prescribed medications. In the experimental group, an average of 1.79 medicines were prescribed, compared to the control group, where the average was 2.26. This is a clearly significant difference (p < 0.001). These results lead us to think that the GED also has potential as an instrument to increase the efficiency and quality of health services in terms of pharmacological prescription. Despite this result, and as we have already commented previously, we believe it is necessary to point out that social changes and poly-medication (41, 42), beyond the effort that all healthcare professionals make to promote reasonable use of medications, is often confronted with the erroneous perception of some patients who measure quality of care from doctors or nurses based on the quantity of medicines prescribed.

4.1. Strengths and limitations

As the main strength of this study we highlight the design, given that to the best of our knowledge, there are no recent experimental studies on demand management in primary care emergency centres (CUAP) for low complexity health problems.

Regarding limitations, our study required a fairly long time to recruit the necessary sample. As it was a voluntary work, both the recruitment of participants and their follow-up, as well as the telephone surveys, had to be adjusted to the on-call shifts of the volunteer nurses and doctors.

The results of the study suggest that the implementation of Nursing Management of Demand (GED) was a factor in improving the efficiency and quality of care in the primary care emergency centre (CUAP). The capacity of nursing for resolution has been shown by the results in the low rate of consultations afterwards for the same reason, a decrease in the prescription of drugs and time off work, and a level of satisfaction comparable to the care provided by doctors. On the other hand, we believe that in order to analyse the potential of GED extrapolated to PC emergencies in a broader territory, it is necessary to implement a second multi-centre experimental project.

PC: Primary Care

PHAMEU: Primary Health Care Activity Monitor for Europe

CUAP: Centro de Urgencias de Atención Primaria

GED: Gestión Enfermera de la Demanda

TREND: Transparent Reporting of Evaluations with Nonrandomized Designs

ECAP: Estación Clínica de Atención Primaria

MAT: Andorran Model of Triage

REDCap: Research Electronic Data Capture

IDIAPJGol : University Institute for Primary Health Care Research Jordi Gol i Gurina

EU: European Union

GDPR: General Data Protection Regulation

PIUC: Comprehensive Emergency Plan of Catalonia

Ethics approval and consent to participate

The study was approved by by the Drug Research Ethics Committee of the Jordi Gol University Institute for Research in Primary Health Care (IDIAPJGol), (22/138-P). All methods were performed in accordance with the Helsinki guidelines. All study participants were informed about the project and signed the consent form, which included detailed information about the study, personal data protection and the participant's right to suspend the transfer of their data or to leave the project at any time during the process. The anonymity of the participants was maintained through data coding.

Consent for publication

Not aplicable.

Availability of data and materials

The datasets used in this study are confdential but available upon request from the corresponding autor.

Competing Interests

The authors declare no competing interests.

Funding

This study is funded by by a nursing scholarship awarded in June 2022 by the Maresme Branch of the Academy of Medical Sciences of Catalonia and the Balearic Islands (Filial del Maresme de la Academia de Ciencias Médicas de Catalunya y Baleares).

Authors' contributions

J,E-C; N,S-A- and R, G-S; were involved in the conceptualization, methodology, as well as the manuscript draft preparation. J,E-C; N,S-A, A,C-CH and S,B-C performed data collection and analysis. P,T-M y A,S-B, performed critical revisions for important intellectual content. All authors were involved in the conduct of the study, and all approved the final version of the manuscript.

Acknowledgements

The authors would like to thank the efforts and commitment of all the nurses who collaborate, day after day, for the recognition of advanced nursing clinical practice and specifically those who promote the autonomous role of nursing in addressing health problems of low complexity in primary care.

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Nurse management of low complexity problems in primary care emergency departments: A non randomised controlled trial

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Abstract

Figures

1. Introduction

2. Method

2.1. Design and participants

1. Presenting any of the following health problems:

2.2. Assignment

2.3. Flows and recruitment

2.4. Analysis of data

2.5. Ethical considerations

3. Results

3.1. Description of the sample and comparison of the groups

3.2. Impact of the intervention on waiting times

3.3. Patient experience

3.4. Consultations for the same reason, incapacity for work and prescribed drugs

4. Discussion

4.1. Strengths and limitations

5. Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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