Urgent Care Needs Among Nonurgent Visits to the Emergency Department.

Letters Obtained funding: Both authors. Administrative, technical, or material support: Prather. Study supervision: Prather. Conflict of Interest Disclosures: Dr Prather is a paid consultant for Posit Science on an unrelated project. No other disclosures were reported. Funding/Support: Dr Prather's involvement was supported by grant K08HL112961 from the National Heart, Lung, and Blood Institute. Dr Leung’s involvement was supported by grant K99HD084758 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 1. Extent and health consequences of chronic sleep loss and sleep disorders. In: Colten HR, Altevogt BM, eds. 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Sleep. 2014;37(1): Urgent Care Needs Among Nonurgent Visits to the Emergency Department 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 non- urgent status in the emer- Editor's Note page 854 gency department (ED) effec- tively ruled out the possibility of serious pathologic conditions, as indicated by visits result- ing in diagnostic screening, procedures, hospitalization, or death, and compared these findings with visits deemed as urgent from triage. Methods | 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 out- comes 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. Results | We analyzed 59 293 observations from 2009 to 2011, representing 240 million visits. A total of 218.49 million vis- its (92.5%) were deemed urgent at triage and 17.76 million vis- its (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 ser- vices, 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%]; electro- cardiograms: 5.8% [95% CI, 4.3%-7.2%]; and any imaging: 28.5% [95% CI, 24.9%-32.0%]), and procedures, such as in- travenous 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 compari- son, diagnostic services were provided in 163.49 million ur- gent 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 admis- sions to critical care units. A total of 27.86 million urgent vis- its (weighted, 12.8% [95% CI, 11.7%-13.8%]) resulted in admis- sions (P < .001), of which only 2.91 million (10.5%; weighted, 1.3% (95% CI, 1.2%-1.5%]) (P = .32) were admissions to criti- cal 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 non- urgent visits, 6 of the top 10 reasons—back symptoms, ab- dominal pain, sore throat, headache, chest pain, and low back pain—were also in the top 10 symptoms reported at urgent vis- its. 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). Discussion | Our study found that a nontrivial proportion of ED visits that were deemed nonurgent arrived by ambu- lance, received diagnostic services, had procedures per- formed, and were admitted to the hospital, including to criti- cal 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 vis- its shows that 50% of these visits are virtually indistinguish- able 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 JAMA Internal Medicine June 2016 Volume 176, Number 6 (Reprinted) Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/ by a UCSF LIBRARY User on 11/18/2016 jamainternalmedicine.com