Safely directing patients to appropriate levels of care: guideline-driven triage in the emergency service.
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.
Washington
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DL
Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA. dwashing@ucla.edu Department of Emergency Medicine, Harb.
Stevens
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CD
Shekelle
P G
PG
Baker
D W
DW
Fink
A
A
Brook
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RH
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