Triaging and Referring In Adjacent General and Emergency Departments: a six-year follow-up study after a cluster randomised trial

Objectives: Emergency department (ED) overcrowding is a persistent issue in European healthcare systems. A previous randomized controlled trial (RCT) concerning out of hours care in Antwerp (2019) demonstrated that a nurse-led triage tool, extending the Manchester Triage System (eMTS), could safely redirect low-acuity ED patients to a co-located General Practitioner Cooperative (GPC). This study reports a six-year follow-up assessing long-term efficiency, safety, and sustainability of this intervention. Methods: We performed a retrospective observational analysis of routine clinical data. Patients triaged at the ED and referred to the GPC were identified through electronic health records. Efficiency outcomes included the proportion of ED patients managed at the GPC, the proportion of GPC patients originating from the ED and their clinical characteristics. To assess safety, we analysed rates and characteristics of patients referred back from the GPC to the ED. A detailed case review was conducted for all back-referred patients. Results: Of the 110,941 triaged patients, 6,722 (6.1%) were managed at the GPC, accounting for 11% of all GPC consultations. Diverted patients typically presented with digestive, respiratory, and musculoskeletal complaints and had a clinical urgency which was mostly comparable to the overall GPC population. Only 3% of the patients diverted to the GPC were referred back to the ED, versus 5% of other GPC patients. Most back-referrals (83%) were managed on an outpatient basis; four major and 18 minor triage issues were identified, without evidence of increased morbidity. Conclusions: Six years post-trial, the nurse-led eMTS triage tool remains integrated into routine practice, with increasing efficiency and remaining safety without dedicated research resources nor a post implementation plan. Sustained adoption highlights its clinical feasibility and long-term safety. Future trials on triage and primary care should embed explicit post-trial implementation strategies to promote continuity and scalability of successful healthcare interventions. ClinicalTrials.gov Identifier: NCT03793972