PRIMARY-CARE IN THE ACCIDENT AND EMERGENCY DEPARTMENT .1. PROSPECTIVEIDENTIFICATION OF PATIENTS

Objective-To compare patient characteristics and consultation activiti es for attenders at accident and emergency departments assessed by nur se triage as presenting with ''primary care'' or ''accident and emerge ncy'' type problems. Design-One year prospective study. Setting-A busy , inner city accident and emergency department in south London. Subjec ts-Of the 5658 patients treated for new problems during a stratified r andom sample of 204 three hour sessions between 10 am and 9 pm during June 1989 to May 1990, all ''primary care'' (2065 patients) and a 10% random sample of ''accident and emergency'' (298 patients) were includ ed in the analysis. Main outcome measures-Patient's age, sex, duration of presenting problem, diagnosis, laboratory and radiographic investi gations, treatments, and referrals. Results-40.9% of attenders with ne w problems were classified by triage as presenting with ''primary care '' problems (95% confidence interval 39.6% to 42.2%). Primary care att enders were more likely than accident and emergency patients to be you ng adults, to have symptoms with a duration of longer than 24 hours, a nd to present problems not related to injury (all P<0.001). Accident a nd emergency patients were considerably more likely to be referred to on call teams and to be admitted. Even so, 9.7% of primary care patien ts were referred to on call teams and a further 8.9% were referred to the fracture clinic or advised to return to the accident and emergency department for follow up. Conclusion-Accident and emergency triage ca n be developed to identify patients with problems that are more Likely to be of a primary care type, and these patients are less likely to r eceive an investigation, minor surgical procedure, or referral. Many p atients in this category, however, receive interventions likely to sup port their decision to attend accident and emergency rather than gener al practice. This may reflect limitations in the sensitivity of triage practice or a clinical approach of junior medical staff that includes a propensity to intervene.