Analysis reveals many ED visits 'virtually indistinguishable' as urgent or nonurgent

A study published by JAMA Internal Medicine found half of the visits to the ED for the top 10 diagnoses are indistinguishable from being urgent or nonurgent.

The purpose of triage in the ED is to prioritize patients who need immediate and urgent care and those who have a nonurgent condition. “We sought to determine whether a triage determination of nonurgent status in the [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,” wrote Renee Y. Hsia, MD, MSc, of the University of California-San Francisco, and colleagues.

The study collected data from the National Hospital Ambulatory Medical Care Survey containing triage scores for ED visits from a triage nurse, based on a scale of 1 to 5, with 1 being immediate and 5 nonurgent. Methodology included focusing on nonelderly adults aged 18 to 64 years and comparing the outcomes of visitslabeled nonurgent with that of visits labeled as urgent between January 1, 2009, to December 31, 2011.

Out of a total of 240 million visits, 218.49 million visits (92.5 percent) were deemed urgent at triage and 17.76 million visits (7.5 percent) as nonurgent. A total of 33.82 million visits (15.5 percent) of those labeled as “urgent” arrived by ambulance, compared with 1.19 million visits (6.7 percent) considered nonurgent. Of the nonurgent visits, a total of 776,000 visits resulted in admissions and of these, 126,000 were admissions to critical care units. A total of 27.86 million urgent visits resulted in admissions, of which only 2.91 million were admissions to critical care units. Overall, a total of 1.01 million nonurgent visits resulted in admission, compared with 32.49 million urgent visits.

After analyzing a nearly 60,000 observation sample, the authors found that for nonurgent visits the study, six 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 found at urgent visits. They also found that five (backache, lumbago, acute upper respiratory infection, cellulitis, and acute pharyngitis) of the top 10 diagnoses for nonurgent patients were identical to the those of urgent patients.

“Our findings indicate that either patients or health care professionals do entertain a degree of uncertainty that requires further evaluation before diagnosis,” concluded Hsia and colleagues. “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 percent of these visits are virtually indistinguishable from each other.”