This study created a structured complaint classification suitable for ED use and implemented it to practice. The classification is based on two stand-alone studies; one focused on identifying presenting complaints from data of 40,610 ED presentations and the other on a two-week survey while using the ICPC-2 as a classification for recording presenting complaints. The study produced a classification based on the ICPC-2, including 89 presenting complaints. The results from implementation were positive and encouraging and the classification is currently in routine use in the Jorvi ED.
Two major factors motivated the selection of the ICPC-2 as the foundation of the new classification. Firstly, the ICPC-2 is symptom-oriented. In the triage process, patients have no predefined diagnoses per se, and the triage nurse’s should base his/her interpretation of urgency and requisite resources on symptoms. Secondly, the ICPC-2 is compatible with the ICD-10. The ICPC-2 is a part of WHO’s Family of International Classifications (FIC) and all of the complaints can be traced back to related ICD-10 codes. However, the ICPC-2 has too much detail for effective use in EDs.
A short list of presenting complaints is simple and reliable, but if the list is too short, it does not present enough information. When the list is long, the specificity is higher but the system is complex and data analysis becomes difficult. With a long list, shortened modifications emerge and their use jeopardizes data comparison. ED-specific presenting complaint lists range between 33  and 165  in the number of different codes. The current study indicates that a list of 89 presenting complaints is well suited for ED use. In triage, time for recording codes is scarce; the system has to be easy to use. Obtaining presenting complaint information from a free text field is very time-consuming and not suitable for routine use.
Unlike the ICPC-2 based classification of this study, Canadian CEDIS classification is ED-specific. Although many presenting complaints are similar in both lists, there are remarkable differences. The main difference in this study’s shorter list is that the presenting complaints of many organs, such as ear, eye, or gynaecological symptoms, are not divided into as many subclasses as those in the CEDIS; patients in these subclasses have the same pathways and use the same resources in EDs. However, the study’s list included more subclasses to code traumas and symptoms of the extremities; symptoms of the ankle, knee, and hip have their own codes. Rare but urgent cases, such as periorbital oedema, were omitted because the inclusion of one such item would soon increase the list with other equally urgent, but rare, symptoms. One must keep in mind that almost all presenting complaints can include emergent cases.
In some cases the CEDIS list had more interpretation of the symptoms than did the list in the current study. The study list, for example, listed hyperventilation with dyspnoe to prevent premature conclusions of possible diagnoses. Hyperventilation can be a harmless symptom, but it can also be a symptom of ketoasidosis or pulmonary embolism. This same principle led to the decision to keep chest pain as one presenting complaint without trying to divide it into more or less specific cardiac features. This is important because a cardiac event is difficult to diagnose .
The ICPC-2 was quite easily modified and suites the classification of ED presenting complaints well. Many codes for the ED list were combined from two or three codes of the ICPC-2. However, some symptoms had to be modified from the ICPC-2. Hyperglycaemia is under abnormal investigation results in the ICPC-2, while hypoglycaemia has its own code and allergic reaction, which the new list had to include despite its features of diagnosis and the fact that it is coded as a diagnosis in the ICPC-2.
Classification of presenting complaints does not remove the need for using free text communication in EDs, it is highly important and codes or rules should not restrict its use. In the Jorvi Hospital ED, the presenting complaint code is not used for communication at all; it is registered only for purposes of data analysis and quality studies and free text is used for communication.
Decisions made in triage regarding urgency and tracks have significant effects on the duration and the quality of the care process. The presenting complaint is one of the most important variables affecting these decisions. The variety of patients entering EDs is wide, and to evaluate triage performance and care quality, divisions between different patient groups are necessary. Often studies concerning EDs make divisions and give treatment recommendations based on diagnoses or treatments but such information is not available at the point of triage. Presenting complaints provide more relevant divisions for studying quality, process, and outcomes of care; for such research, structured information regarding presenting complaints is essential.
In addition, routine research in the classification of presenting complaints in ERs enables several practical data usage possibilities. Presenting complaint information, for example, aids demand and capacity planning, streaming, and patient flow control, quality control, and benchmarking of performance.
Although the studied EDs represent medium-sized joint EDs, which are typical to Finnish healthcare system, there may be need for customization and for more detailed presenting complaints classification in highly specialized units. Moreover, the new classification was tested only in one ED and to ensure reliability and validity with different case-mixes further studies may be needed.
It should be noted that the evaluation method of new classification is not strictly following any qualitative method and is not reported according to any qualitative standard.
All classifications need continuous improvement. Therefore, our study classification is not suitable for broad use without centralized national or international actor for development. The study focused only in adult patients and the classification is not directly generalizable to presenting complaints of children.