There are studies [12,15] suggesting that neither waiting times nor delays are directly correlated with resources or demand, but rather with how smoothly the processes of working are in an ED. Additional studies are needed to characterize the patients who visit tertiary care EDs without a pre-check by the primary health care in order to improve patient flow in an ED of the kind

described in this study. The number of visits to primary care doctors during office hours was unchanged during 2003-2005 in both Vantaa and Espoo (Figure ​(Figure2).2). Thus, the decrease in the patient visits to the Inhibitors,research,lifescience,medical GPs of see more Peijas ED did not cause an overflow of patients in the office hour general practice. There seems to be no extra work load for the daytime doctor services. Our results are in line with the suggestion

that EDs also have customers of their own and that those patients are not likely to use ordinary day time services of the primary health care system [4]. Inhibitors,research,lifescience,medical The change in the number of visits to the private sector GPs was similar in Vantaa, where the triage was applied, as compared with the control Inhibitors,research,lifescience,medical community Espoo (Figure ​(Figure3).3). There is evidence that there is a correlation between public and private sectors with respect to the need of health care and health care utilization [16]. If the demand for health care is considered to be unsatisfactory in the public sphere patients look for care in private sector institutes [17]. No such shift was seen in the current study. Even though the access Inhibitors,research,lifescience,medical for non-immediate patients to Peijas’ combined ED was made more inconvenient by using ABCDE triage, the patients in Vantaa did not seek help from the private sector more often than those who had unlimited access to the ED in the control city (Espoo). Actually, the use of private sector GPs was more frequent in Espoo where no ABCDE-triage was applied. Patient safety issues are important when applying triage in an ED. The

key player in the present triage model is the nurse who makes the initial assessment of the patient upon arrival. In our previous report, no extra false diagnoses Inhibitors,research,lifescience,medical or complications were observed when non-urgent patients were allocated to the slowest triage group (waiting up to 5-6 hours at worst times [10]). This agrees with the finding that in many EDs around the world triage has been successfully run by experienced nurses [11,13,18]. Furthermore, there are reports suggesting that crotamiton some activities formerly performed by physicians in primary health care were safely performed by trained nurses [19]. The quality of triage must be continuously monitored and the number of incorrect assessments minimized. Right now further studies are ongoing on the safety of the present triage system and on the waiting time changes induced by it. Preliminary data from Vantaa seems promising in safety issues [10] but more detailed studies must be carried out.