title: Safely directing patients to appropriate levels of care: guideline-driven triage in the emergency service.
abstract: OBJECTIVE
  We sought to develop and validate standardized clinical criteria to identify patients presenting to the emergency department whose care may be safely deferred to a later date in a nonemergency setting.
  
  
  METHODS
  Using a modified Delphi process, a 17-member multidisciplinary physician panel developed explicit, standardized, deferred-care criteria. In a prospective cohort design, emergency nurses at a tertiary care Veterans Administration (VA) Medical Center, using the criteria, screened 1,187 consecutive ambulatory adult patients presenting with abdominal pain, musculoskeletal symptoms, or respiratory infection symptoms. Patients meeting deferred-care criteria were offered the option of an appointment within 1 week in the ambulatory care clinic at the study site; all other patients were offered same-day care. As outcome measures, we assessed nonelective hospitalizations for related conditions occurring within 7 days of evaluation at our facility or any other VA facility within a 300-mile radius, and we assessed 30-day all-cause mortality.
  
  
  RESULTS
  Two hundred twenty-six (19%) patients met screening criteria for deferred care. Patients meeting deferred-care criteria experienced zero (95% confidence interval, 0% to 1.2%) related nonelective VA hospitalizations within 7 days of evaluation, and none died within 30 days. By contrast, 68 (7%) of 961 (95% confidence interval, 5.5% to 8.9%) patients who did not meet deferred-care criteria were hospitalized nonelectively for related conditions, and 5 (0.5%) died.
  
  
  CONCLUSIONS
  By using hospitalization and 30-day mortality as safety gauges, standardized clinical criteria can identify, at presentation, VA ED users who may be safely cared for at a later date in a nonemergency setting. These guidelines apply to a significant proportion of VA ED users with common ambulatory conditions. These criteria deserve testing in other ED settings.
authors.affiliation: Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA. dwashing@ucla.edu Department of Emergency Medicine, Harb.
authors.forename: D L
authors.initials: DL
authors.lastname: Washington
authors.forename: C D
authors.initials: CD
authors.lastname: Stevens
authors.forename: P G
authors.initials: PG
authors.lastname: Shekelle
authors.forename: D W
authors.initials: DW
authors.lastname: Baker
authors.forename: A
authors.initials: A
authors.lastname: Fink
authors.forename: R H
authors.initials: RH
authors.lastname: Brook
mesh_terms: D000328:Adult; D000368:Aged; D003697:Delphi Technique; D004636:Emergency Service, Hospital; D005260:Female; D006300:Health Services Misuse; D006304:Health Status; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010343:Patient Admission; D010348:Patient Care Team; D017410:Practice Guidelines as Topic; D015996:Survival Rate; D014218:Triage