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Patients triaged as nonurgent in ED get diagnostics, procedures, admitted

Some patients triaged as nonurgent in emergency departments (EDs) still received diagnostic services, had procedures performed and were admitted, including to critical care units, all of which could signal overuse, a lack of primary care physicians or a degree of uncertainty by patients and physicians, according to a new study published online by JAMA Internal Medicine.

Triaging patients prioritizes who most urgently needs to be seen in an ED and it is essential to providing care for the sickest patients.

Renee Y. Hsia, M.D., MSc., of the University of California, San Francisco, and coauthors looked at whether a triage determination of “nonurgent” in the ED effectively ruled out the possibility of serious pathologic conditions (indicated by diagnostic screening, procedures, hospitalization or death) and compared those findings with those visits triaged as urgent.

The authors examined characteristics and outcomes of visits from 2009 to 2011 for adults ages 18 to 64. They analyzed 59,293 observations, representing 240 million visits. A total of 218.5 million visits (92.5 percent) were triaged as urgent and almost 17.8 million visits (7.5 percent) were triaged as nonurgent.

The authors report that diagnostic services, such as blood tests, electrocardiograms and imaging, were provided in 8.4 million (47.6 percent) nonurgent visits and procedures such as intraveneous fluids, casting and splinting were performed in almost 5.8 million (32.4 percent) nonurgent visits. Comparatively, diagnostic services were provided in 163.5 million urgent visits (74.8 percent) and procedures were performed in 107.9 million urgent visits (49.4 percent).

Also, 776,000 nonurgent visits (4.4 percent) resulted in hospital admissions and 126,000 (16.2 percent) were critical care unit admissions. In comparison, 27.9 million urgent visits (12.8 percent) resulted in admissions and 2.9 million (10.5 percent) were admissions to critical care units, the result show. Additionally, about 1 million nonurgent visits (5.7 percent) resulted in admission or transfer compared with 32.5 million urgent visits (14.9 percent).

Further analysis showed that six of the top 10 symptoms (back symptoms, abdominal pain, sore throat, headache, chest pain and low back pain) reported at nonurgent visits also were in the top 10 symptoms reported at urgent visits.

Of the top 10 diagnoses from nonurgent visits, five of them were identical to those diagnoses at urgent visits (backache, lumbago, acute upper respiratory infection, cellulitis and acute pharyngitis, which is a sore throat), according to the results.

Authors note the original intention of triaging was to predict the amount of time patients could safely wait to be seen in an ED and triaging was never intended to completely rule out severe illness as a possibility in someone considered nonurgent.

“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,” the authors conclude.