Many ‘nonurgent’ ED cases actually are urgent

Many emergency department cases deemed “nonurgent” by triage personnel actually are indistinguishable from those deemed “urgent,” according to a Research Letter to the Editor published in JAMA Internal Medicine.

To examine whether a triage determination of nonurgent status really rules out the possibility of serious pathology, researchers analyzed data from the National Hospital Ambulatory Medical Care Survey, a representative annual probability sample survey of ED visits categorized by level of urgency. They focused on 59,293 ED visits by patients aged 18-64 years during a 3-year period, which were representative of 240 million ED visits across the country. An estimated total of 218.5 million of these visits (92.5%) were categorized as urgent and 17.8 million (7.5%) as nonurgent by triage personnel, said Dr. Renee Y. Hsia of the department of emergency medicine and the Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, and her associates.

Patients required diagnostic services such as blood tests, electrocardiograms, or imaging in 8.45 million “nonurgent” visits (48%), and patients required procedures such as intravenous fluids, casting, or splinting in 5.76 million “nonurgent” visits (32%). More than 775,000 “nonurgent” visits (4%) resulted in hospital admission, including 126,000 admissions to critical care units. And in 1.19 million “nonurgent” visits (7%), patients arrived by ambulance.

In addition, half of the top 10 diagnoses from “nonurgent” visits were identical to those from urgent visits, the investigators said (JAMA Int Med. 2016 April 18. doi: 10.1001/jamainternmed.2016.0878).

“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. 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,” Dr. Hsia and her associates said.

Triage was never intended to completely rule out the possibility of severe illness in patients considered nonurgent, but was meant to predict the amount of time a patient could safely wait to be seen in the ED. However, over time, “the term ‘nonurgent’ has been often politicized to mean ‘inappropriate,’ ” they noted.

“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,” the investigators said.

Many emergency department cases deemed “nonurgent” by triage personnel actually are indistinguishable from those deemed “urgent,” according to a Research Letter to the Editor published in JAMA Internal Medicine.

To examine whether a triage determination of nonurgent status really rules out the possibility of serious pathology, researchers analyzed data from the National Hospital Ambulatory Medical Care Survey, a representative annual probability sample survey of ED visits categorized by level of urgency. They focused on 59,293 ED visits by patients aged 18-64 years during a 3-year period, which were representative of 240 million ED visits across the country. An estimated total of 218.5 million of these visits (92.5%) were categorized as urgent and 17.8 million (7.5%) as nonurgent by triage personnel, said Dr. Renee Y. Hsia of the department of emergency medicine and the Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, and her associates.

Patients required diagnostic services such as blood tests, electrocardiograms, or imaging in 8.45 million “nonurgent” visits (48%), and patients required procedures such as intravenous fluids, casting, or splinting in 5.76 million “nonurgent” visits (32%). More than 775,000 “nonurgent” visits (4%) resulted in hospital admission, including 126,000 admissions to critical care units. And in 1.19 million “nonurgent” visits (7%), patients arrived by ambulance.

In addition, half of the top 10 diagnoses from “nonurgent” visits were identical to those from urgent visits, the investigators said (JAMA Int Med. 2016 April 18. doi: 10.1001/jamainternmed.2016.0878).

“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. 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,” Dr. Hsia and her associates said.

Triage was never intended to completely rule out the possibility of severe illness in patients considered nonurgent, but was meant to predict the amount of time a patient could safely wait to be seen in the ED. However, over time, “the term ‘nonurgent’ has been often politicized to mean ‘inappropriate,’ ” they noted.

“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,” the investigators said.

Many emergency department cases deemed “nonurgent” by triage personnel actually are indistinguishable from those deemed “urgent,” according to a Research Letter to the Editor published in JAMA Internal Medicine.

To examine whether a triage determination of nonurgent status really rules out the possibility of serious pathology, researchers analyzed data from the National Hospital Ambulatory Medical Care Survey, a representative annual probability sample survey of ED visits categorized by level of urgency. They focused on 59,293 ED visits by patients aged 18-64 years during a 3-year period, which were representative of 240 million ED visits across the country. An estimated total of 218.5 million of these visits (92.5%) were categorized as urgent and 17.8 million (7.5%) as nonurgent by triage personnel, said Dr. Renee Y. Hsia of the department of emergency medicine and the Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, and her associates.

Patients required diagnostic services such as blood tests, electrocardiograms, or imaging in 8.45 million “nonurgent” visits (48%), and patients required procedures such as intravenous fluids, casting, or splinting in 5.76 million “nonurgent” visits (32%). More than 775,000 “nonurgent” visits (4%) resulted in hospital admission, including 126,000 admissions to critical care units. And in 1.19 million “nonurgent” visits (7%), patients arrived by ambulance.

In addition, half of the top 10 diagnoses from “nonurgent” visits were identical to those from urgent visits, the investigators said (JAMA Int Med. 2016 April 18. doi: 10.1001/jamainternmed.2016.0878).

“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. 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,” Dr. Hsia and her associates said.

Triage was never intended to completely rule out the possibility of severe illness in patients considered nonurgent, but was meant to predict the amount of time a patient could safely wait to be seen in the ED. However, over time, “the term ‘nonurgent’ has been often politicized to mean ‘inappropriate,’ ” they noted.

“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,” the investigators said.