In the current study we report the results of a program of nurse algorithm-guided care for adult patients with acute minor illnesses in primary care in a very large cohort of patients (1,209,669 consultations) over a two-year period. The program was designed to fulfill two criteria: treatment algorithms and close collaboration between nurses and GPs. The program was also intended to solve some of the concerns raised about the effectiveness and appropriateness of extending the role of nurses to same day consultations for acute minor illnesses in primary care, thus substituting GPs in this function. One of these concerns is that nurses may work independently of GPs which may result in lack of consultation in the case of uncertainty . To avoid this potential effect, the program reported herein was the result of a collective effort between GPs and nurses. Moreover, in all management algorithms a number of signs of alarm were included, so that patients had to be sent to the GP for an urgent consultation if one of the signs of alarm was present. Another concern is that patients, at least in some countries, are not convinced that nurses have the sufficient education and knowledge to deal with these type of problems compared to GPs [11–14]. The close cooperation between nurses and GPs put forward in our program may help convince patients that nurses have the sufficient expertise to solve the problems in the majority of cases and that a consultation with the GP will be requested in case of uncertainty. A major issue that has limited the applicability of programs of nurse same day consultation for patients with acute minor illnesses in many countries has been the fact that nurses cannot prescribe certain drugs. On the other hand, nurses may have the feeling of a lack of appropriate pharmacological knowledge together with insufficient confidence in this area. The use of management algorithms allows restricting the drug prescription to certain conditions, following evidence-based guidelines. Moreover, the use of management algorithms may have the additional benefits of improving the adherence to protocols and reducing inter-professional variability in their application. Finally, the incorporation of the management algorithms in the computerized health record system is essential for their accurate application and also allows for a periodical assessment of the efficacy of the program.
The program reported here has some similarities with the walk-in centers from United Kingdom . These are centers specifically created to provide care to patients with minor illnesses (minor injuries in many instances), which are usually run by nurses. However, there are significant differences that should be mentioned. First, our program was run in general practices and not in new and specific centers. Second, the program was devoted to a large number of acute minor illnesses that represent an important workload in primary care. Third, although the program was run by nurses, there was a close cooperation between nurses and GPs, which allowed the resolution of complex cases. Finally, the fact that the program was set at the general practice allowed a continuity of care.
Our results indicate that the rate of resolution achieved by nurses in 16 different minor illnesses is high (62.5%), with low probability of return to consultation for the same reason (below 5%). Interestingly, case resolution during the second year was higher compared to that of the first year, indicating that greater experience with the management algorithms resulted in an improved case resolution. We observed marked differences in the rate of case resolution between different conditions. For example, case resolution for burns and skin injury were much higher (over 90%) than those for lower urinary symptoms and upper respiratory symptoms, which did not reach 50%. Not resolved cases were sent to the GP for urgent consultation. Differences between resolution rates of the various minor illnesses might be related to the fact that some conditions correspond to long-established nurse practice (i.e. skin injury, burns) while others do not (i.e. upper respiratory symptoms, lower urinary symptoms). The relatively low resolution rate for these latter conditions probably indicates the compliance with signs of alarm that prompted referral to the GP as well as a high sense of responsibility of nurses in not assuming too complex processes. The rates of effectiveness in case resolution observed in the current study are high and support an approach using management algorithms for acute minor illnesses in primary care.
A limitation of the study is that case resolution was defined whenever the treatment protocol could be completed and treatment prescribed without the need of referral of the patient to the GP. Therefore, the resolution of the symptoms was not confirmed directly with the patient. Direct confirmation with the patient is hardly possible in a “real life” scenario. Return to consultation to primary care, either with a nurse or GP, was very low, averaging only 4.6%, which is keeping with the high rate of case resolution observed. It is important to note, however, that some patients could have requested a second consultation outside primary care and could have not been captured by the system. It is important to mention that patients’ satisfaction was not assessed in the current study. Therefore, the degree of satisfaction of patients by having been visited by a nurse instead of a GP could not be estimated. Randomized studies have demonstrated that in patients requesting same day consultation in primary care, the degree of satisfaction is greater when patients are treated by nurses than when they are treated by GPs [4, 6, 7, 16]. There are however other studies with discrepant findings . Finally, we did not evaluate the impact of the current approach in terms of cost. Further research will be required to evaluate the cost-effectiveness of the approach presented in this study.