FAMILY PRACTICE AWARENESS IN PATIENTS APPLYING TO THE EMERGENCY DEPARTMENT AND RECEIVING A GREEN TRIAGE CODE ACİL SERVİSE BAŞVURAN VE YEŞİL TRİYAJ KODU ALAN

Objectives: In our country and all over the world, the overcrowding of Emergency Service is seen as a problem. Our goal in this study is to determine Family Practice awareness of patients who applies to Emergency Service with green triage code and to find out reasons for using Emergency Service instead of Family Practice. Materials and Methods: This study was performed in a training and research hospital emergency department for one month of the period. After patients, who applied to Emergency Service, were evaluated in Triage Department, the patients with Green Triage Code were assessed by a physician. Patients without acute emergency pathology were informed about the study, and informed consent was taken. It was provided to patients to answer the questionnaire. One thousand twenty-six patients were taken to the study and divided into two groups as emergencies and non-emergencies. Results: There were 305 patients in the emergency group, and there were 721 patients in non-emergency group. There was no significant difference between an emergency and non-emergency group according to gender, age, education, and the number of emergency applications. The most frequent application was from the younger group of 18-29 age range in both groups. With the increase in the patient age, the number of applications to the Emergency Department due to emergency and non-emergency reasons decreased. 57.30% of the patients who applied to the Emergency Department for non-emergency reasons know who the Family Physician is; 42.70% stated that they did not know who the Family Physician was. 52,10% of the patients who applied to the Emergency Department for non-emergency reasons stated that they knew the location of the health center where the Family Physician worked, and 47.90% of them stated that they did not know the location of the health center where the Family Physician worked. Conclusion: It can be provided to reduce the density of Emergency Service by creating Family Practice awareness. Application difficulties in Family Practice lead patients to apply to Emergency Service more. We believe that to ease application to Family Practice could reduce redundant applications to Emergency Service.


Introduction
According to the description made by WONCA (World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians) Europe Region in 2002, Family Practice (FP), alias General Practice, is an academic and scientific discipline with its own educational content, research, evidence-based, and clinical practice and a clinical specialty orientated to primary care. Family practice is the first step of medical relations. FP cares everybody who is registered in its tract regardless of their ages, genders, or any characteristic of them. It develops an individual-based approach oriented person, his/her family, and society. It manages acute and chronic health problems of patients simultaneously. Most of the health problems that require application to physicians could be managed in primary care. FP encounters complaints, signs, and the early stages of the diseases; therefore, based on the symptoms, non-specific, and large number of diagnoses could be diagnosed in FP. It is expected from FP to consider psycho-social and cultural integrity, to reduce or to resolve complaints in a short time, and to diagnose by taking advantage of the patient's prior knowledge. As a result of studies, we concluded that 90% of symptoms and diseases could be solved in the first stage. Represcription of chronic medications of the patients, repeater, according to the physicians, is one of the most common issues that FP is facing. [1][2][3][4] Emergency Services (ES) are units providing health care to the people having a disease that could end up with severe pain, injury, or death without immediate treatment. A precise definition of the concept of emergency aid and urgent cases is very difficult. Thus each patient who thinks that he/she is an emergency patient, who stated that he/she is an emergency patient and who applied to ES should be evaluated. Until proven otherwise, the patient applied to ES should be evaluated as an emergency patient. None of the patients could be concluded as non-emergency without a full assessment. In our country and all over the world, the overcrowding of ES is seen as a problem. Despite the studies aiming to exclude non-emergency patients from ES, applications to ES have been increased by 20% over the past decade. Patients think that every problem of them is an emergency. Using ES inopportunely causes personnel to lose time and attention. This poses an obstacle to the real emergent patients that should be devoted more time and attention. A better triage system should be implemented to avoid this situation. [5][6][7] The word triage is originated from the French word 'trier,' and it means 'to select,' 'to eliminate,' 'to separate' and 'to debug.' Today, modern triage is used to distinguish the patients who are waiting for medical help and have the potential for dangerous situations from the others; also, it is used to provide more effective care in situations that affect too many people and are called a disaster. It could be identified as aligning the priorities of patient care according to the severity and prognosis of the injury or disease and available sources. With the increasing number of patients applying to ES, especially with a low degree of urgency, triage has taken its place in routine use to able to give primary care to emergency patients. [8][9][10] According to the 'Communiqué on Implementation Procedures and Principles of Emergency Service in Health Facilities with Bed' produced by the Ministry of Health and proclaimed in the gazette in 2009; red is used for worst emergency patient, yellow is used for emergency patient and green for non-emergency patient. [9][10][11] In our country and all over the world, the overcrowding of ES is seen as a problem. Our goal in this study is to determine FP awareness of patients who applies to ES with green triage code and to find out reasons for applying to ES instead of FP.

Materials and Methods
This study was performed in the Emergency Medical Clinic of Sisli Etfal Training and Research Hospital after the acceptance of hospital administration with the number of 04-01-2012/262. After the evaluation of patients who applied to ES in the triage department, patients with green triage code (GTC) were evaluated in the green department (GD) by an emergency medicine physician who does not know of the study. Patients who were not diagnosed as emergency pathology after the necessary examinations and tests were informed about the study.
Patients who agreed to participate in the study and signed an informed consent form were included in the study and provided to fill the questionnaire. Foreign nationals, patients arrive at the emergency department via the ambulance, and patients under the age of 18 were excluded. One thousand twenty-six patients included in the study were divided into two groups as emergency patients and non-emergency patients. Emergency patient group was consist of patients with minor injuries, who requires many resources, who requires first aid and initial management, and with comorbid diseases. Patients with chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM) or cardiac disease could use adjuvant medical equipment and multiple drugs or could not do their daily tasks without help; these situations were considered as comorbid diseases. Nonemergency patient group was consist of patients who can wait without any resource use, without any injuries, who do not need any initial management. The non-emergency group patients are using ES because of the health system in our country. All patients who admit to ES are considered as emergency patients in our health system, and after the initial examination the patients are discharged from the hospitals if they don't have any emergency condition. This is why we have a non-emergency patient group.

Statistical method
Frequency and ratio values were used in the descriptive statistics of datum. A chi-square test was used when analyzing proportional datum. Fischer-exact test was used when the chi-square test's conditions couldn't be provided. SPSS 19.0 software was used for analysis.

Results
Twenty thousand one hundred fourteen patients were applied to ES during the month of study. Eight thousand nine hundred twenty-four of these patients took green triage code. One thousand twenty-six patients eligible for the study criteria were taken to the study. There were 305 patients in the emergency group, and there were 721 patients in non-emergency group. Five hundred fifty-five of the patients in the study were female, 471 were male. 54.10% of the patients applied to ES as emergency and non-emergency were female, and 45.90% of them were male. The most frequent application was from the younger group of 18-29 age range in both groups. In both groups, the most frequent applicants were primary school graduates. The frequencies of admission to ES were higher in first application in both groups, followed by 2-3 times group (Table 1).  When we examined conditions of chronic disease in the history of patients, the most common diseases were COPD and heart diseases in both groups. They were followed by patients with co-morbid diseases (Figure 1).
When assessing health facility uses, we determined that FP was preferred more than ES for repeated prescriptions; the rate of ES preferability was 14.10%. ES was more preferred for injection and dressing.
57.30% of the non-emergency patients knew their family physicians, but only 22.10% of them knew the names of their family physicians. Almost half of the patients did not know the location of the family physician center (FPC), and only 44.1% of them said that they had applied to FP before. 61.80% of patients substantiated distance of FPC for not-applying to FP, only 0.70% of them said that they do not trust family physician. 35% of the non-emergency patients in the ES application group indicated that they applied to ES for dressing and injection. 14.80% of the green code patients who are not considered as emergency patients stated that they apply to FP for injection and dressing. We have seen that 55.90% of non-emergency patients applied to ES have never applied to FP before. When we examined their reasons to not apply to FP, we realized that 37.20% of the patients didn't know their FP, and 61.80% of them didn't apply because of accession difficulties despite knowing their FP. We determined that social insurance and proximity were the most common reasons for applying ES, the ratio was 70.30% (Table 2). In the study of Aydin et al., they stated that there is overcrowding and improper using in ES nationwide. They also emphasized that this overcrowding leads personnel to lose time and attention. In this case, they couldn't spare time to emergency patients who need time and attention, so they are influenced negatively. 7 In our study, 35% of the non-emergency patients in the ES application group indicated that they applied to ES for dressing and injection. 14.80% of the green code patients who are not considered as emergency patients stated that they apply to FP for injection and dressing. Providing service only within studying hours of FP and being convenient after studying hours due to daily study routine of patients could be reasons for this situation. To create patients' awareness about applying to FP for injection and dressing could reduce overcrowding in ES and provide more efficient studying environment for ES personnel.
When we analyzed the reasons for ES preference, we determined that social insurance and proximity were the most common reasons for applying ES. In the study of Worthington et al., they stated that reasons for patients' preferring ES could be their following recommendations made by other patients who previously get qualified service in ES and social insurance issues. 12 Cooke et al. emphasized that 29.40% of patients who examined by ES physicians don't need further investigation or any treatment. 13 In our study, this ratio was 70.30%. The reason for this could be that our studying group patients were among green code patients instead of all patients.  16 In our study, it seems that elementary and high school education has the highest rates. In the region of our hospital, there are a lot of business centers, and employees of these business centers prefer our hospital due to their social insurances, we think that this is the reason of those rates.
In our study, when we analyze the application frequency to ES, it is shown that the percentage of the patients who didn't apply to ES is 48.70% in the last month, but the percentage of the patients who reapplied to ES 2-3 times is 39.90%. We think that the reason for this is patient satisfaction in our ES.
When we examine the non-emergency group of ES patients, we found out that 14.10 of the patients prefer to come to ES for the re-prescription of the medicines they use. Emergency services could also be accessed in out of studying hours due to its round the clock service, and they provide services free thanks to Circular entitled 'Abolition of the Cash Desk in Emergency Services,' dated 31/01/2011 and numbered 4601, issued by the Ministry of Health. So these lead patients to prefer ES. 17 However, it is a fact that this situation increases overcrowding in ES. If we create awareness about that family physicians could follow-up the patients who want their medicines to be pre-prescribed and evaluate their medicines according to this follow-up, this could prevent the applications for chronic follow-up and improve productivity of ES.
In the study of Cetinkaya et al., they asked the patients the question, " Which medical institution do you prefer when you or one of your family members become sick? ", 49.70% of the patients said they generally use family practices, 25.10% said private hospitals/polyclinics, 16.50% said public hospitals, and 8.70% said they prefer training hospitals. As the reason for preferring these institutions, 39.20% of them said that their reason to prefer facilities is proximity, 18.60% said that technical opportunities are better than the others in the facilities they choose for health care, 4.20% said that they prefer the facilities because they have acquaintances in there and 2.90% indicated that they make their decisions according to financial situations. 18 In our study, we have seen that 55.90% of non-emergency patients applied to ES have never applied to FP before. When we examined their reasons to not apply to FP, we realized that 37.20% of the patients didn't know their FP, and 61.80% of them didn't apply because of accession difficulties despite knowing their FP. However, FP units were determined according to their registered address within the scope of the "health conversion project" by the Ministry of Health. It was also planned to deploy FP centers in easily accessible places that were identified on the map for family physicians. 19 The reason for opposing our work, and this situation could be based on that work area of the study, is a metropole city and accession to hospitals is easy due to public transports.
Eventually, the patients who want to re-prescribe their medicines and who need injection or dress prefer to apply ES. This situation causes overcrowding in ES. By creating awareness about FP, overcrowding in ES could be reduced. Difficulties while applying to FP lead patients to apply to ES. We think that improper applications to ES could be reduced by providing convenience in applying to FP.