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Hsia RY, Friedman AB, Niedzwiecki M. Urgent Care Needs Among Nonurgent Visits to the Emergency Department. JAMA Intern Med. 2016;176(6):852–854. doi:10.1001/jamainternmed.2016.0878
The goal of triage is to prioritize patients who need to be seen most urgently; it is essential for providing the highest quality of care to the sickest patients.1 We sought to determine whether a triage determination of nonurgent status in the emergency department (ED) effectively ruled out the possibility of serious pathologic conditions, as indicated by visits resulting in diagnostic screening, procedures, hospitalization, or death, and compared these findings with visits deemed as urgent from triage.
The National Hospital Ambulatory Medical Care Survey is a national multistage probability sample survey of patient visits to the ED. These data contain triage scores for each ED visit as assessed by a triage nurse on arrival based on a scale of 1 to 5, with 1 being immediate, 2 emergent, 3 urgent, 4 semi-urgent, and 5 nonurgent.2 We compared characteristics and outcomes of visits from January 1, 2009, to December 31, 2011, labeled as nonurgent (category 5) with characteristics and outcomes of visits with all other labels (categories 1-4), which we labeled as urgent visits. We focused on nonelderly adults aged 18 to 64 years and excluded visits for which triage scores were missing or where the patient left before triage or medical screening. This study was deemed exempt from human subjects review at the University of California San Francisco.
We analyzed 59 293 observations from 2009 to 2011, representing 240 million visits. A total of 218.49 million visits (92.5%) were deemed urgent at triage and 17.76 million visits (7.5%) as nonurgent. A total of 33.82 million visits (15.5%) deemed urgent arrived by ambulance, compared with 1.19 million visits (6.7%) considered nonurgent. Diagnostic services, such as blood tests, electrocardiograms, and imaging, were provided in 8.45 million nonurgent visits (47.6%) (any blood tests: weighted, 18.8% [95% CI, 15.5%-22.1%]; electrocardiograms: 5.8% [95% CI, 4.3%-7.2%]; and any imaging: 28.5% [95% CI, 24.9%-32.0%]), and procedures, such as intravenous fluids, casting, and splinting, were performed in 5.76 million nonurgent visits (32.4%) (intravenous fluids: weighted, 12.6% [95% CI, 9.7%-15.6%]; casting: 0.6% [95% CI, 0.2%-1.0%]; and splinting: 6.2% [95% CI, 5.2%-7.3%]). In comparison, diagnostic services were provided in 163.49 million urgent visits (74.8%) (any blood tests: weighted, 46.2% [95% CI, 44.7%-47.6%]; electrocardiograms: 18.7% [95% CI, 17.8%-19.6%]; and any imaging: 49.0% [95% CI, 47.7%-50.3%]), and procedures were performed in 107.89 million urgent visits (49.4%) (intravenous fluids: weighted, 31.7% [95% CI, 30.2%-33.3%]; casting: 0.3% [95% CI, 0.2%-0.3%]; and splinting: 5.6% [95% CI, 5.3%-5.9%]) (P < .001 for all comparisons) (Table 1).
A total of 776 000 nonurgent visits (weighted, 4.4% [95% CI, 3.1%-5.7%]) resulted in admissions and of these, 126 000 (16.2%; weighted, 0.7% (95% CI, 0.1%-1.3%]) were admissions to critical care units. A total of 27.86 million urgent visits (weighted, 12.8% [95% CI, 11.7%-13.8%]) resulted in admissions (P < .001), of which only 2.91 million (10.5%; weighted, 1.3% (95% CI, 1.2%-1.5%]) (P = .32) were admissions to critical care units. Overall, 1.01 million nonurgent visits (weighted, 5.7% [95% CI, 4.2%-7.1%]) resulted in admission or transfer, compared with 32.49 million urgent visits (weighted, 14.9% [95% CI, 13.8%-15.9%]) (P < .001) (Table 2).
When we examined the chief symptoms reported at nonurgent visits, 6 of the top 10 reasons—back symptoms, abdominal pain, sore throat, headache, chest pain, and low back pain—were also in the top 10 symptoms reported at urgent visits. In addition, when the top 10 diagnoses from nonurgent visits were analyzed, 5 were identical to those at urgent visits (backache, lumbago, acute upper respiratory infection, cellulitis, and acute pharyngitis).
Our study found that a nontrivial proportion of ED visits that were deemed nonurgent arrived by ambulance, received diagnostic services, had procedures performed, and were admitted to the hospital, including to critical care units. Certainly, not all of these data necessarily indicate that these services were required, and they could signal overuse or a lack of availability of primary care physicians.3 However, to some degree, our findings indicate that either patients or health care professionals do entertain a degree of uncertainty that requires further evaluation before diagnosis. That half of the top 10 diagnoses, among over 14 000 International Classification of Diseases, Ninth Revision codes, are found in both nonurgent and urgent visits shows that 50% of these visits are virtually indistinguishable from each other.
There are certain limitations to this study. Specifically, while the National Hospital Ambulatory Medical Care Survey uses a 5-level triage score, not all hospitals do. The National Hospital Ambulatory Medical Care Survey therefore rescales visits to hospitals that do not use a 5-level triage score, and also imputes missing values. When we repeated our analysis without imputed values, we found similar results.
The original intention of triage—to predict the amount of time a patient could safely wait to be seen in the ED—was never intended to completely rule out the possibility of severe illness in a patient considered nonurgent. However, the rhetoric behind the term nonurgent has been often politicized to mean inappropriate, which has implications for both the patient and health care system when these 2 terms are conflated. Our findings highlight the lack of certainty of nonurgent status even when it is determined prospectively by a provider at triage and suggest that caution must be taken when using triage scores beyond their intended purpose.
Corresponding Author: Renee Y. Hsia, MD, MSc, Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, Room 1E21, San Francisco, CA 94110 (firstname.lastname@example.org).
Published Online: April 18, 2016. doi:10.1001/jamainternmed.2016.0878.
Author Contributions: Dr Niedzwiecki had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Hsia, Friedman.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Hsia, Friedman.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Friedman, Niedzwiecki.
Administrative, technical, or material support: Hsia.
Study supervision: Hsia.
Conflict of Interest Disclosures: None reported.