title: Categorizing urgency of infant emergency department visits: agreement between criteria.
abstract: BACKGROUND
  The lack of valid classification methods for emergency department (ED) visit urgency has resulted in large variation in reported rates of nonurgent ED utilization.
  
  
  OBJECTIVE
  To compare four methods of defining ED visit urgency with the criterion standard, implicit criteria, for infant ED visits.
  
  
  METHODS
  This was a secondary data analysis of a prospective birth cohort of Medicaid-enrolled infants who made at least one ED visit in the first six months of life. Complete ED visit data were reviewed to assess urgency via implicit criteria. The explicit criteria (adherence to prespecified criteria via complete ED charts), ED triage, diagnosis, and resources methods were also used to categorize visit urgency. Concordance and agreement (kappa) between the implicit criteria and alternative methods were measured.
  
  
  RESULTS
  A total of 1,213 ED visits were assessed. Mean age was 2.8 (SD +/- 1.78) months, and the most common diagnosis was upper respiratory infection (21.0%). Using implicit criteria, 52.3% of ED visits were deemed urgent. Urgent visits using other methods were as follows: explicit criteria, 51.8%; ED triage, 60.6%; diagnosis, 70.3%; and resources, 52.7%. Explicit criteria had the highest concordance (78.3%) and agreement (kappa = 0.57) with implicit criteria. Of limited data methods, resources demonstrated the best concordance (78.1%) and agreement (kappa = 0.56), while ED triage (67.9%) and diagnosis (71.6%) exhibited lower concordance and agreement (kappa = 0.35 and kappa = 0.42, respectively). Explicit criteria and resources equally misclassified urgency for 11.1% of visits; ED triage and diagnosis tended to overclassify visits as urgent.
  
  
  CONCLUSIONS
  The explicit criteria and resources methods best approximate implicit criteria in classifying ED visit urgency in infants younger than six months of age. If confirmed in further studies, resources utilized has the potential to be an inexpensive, easily applicable method for urgency classification of infant ED visits when limited data are available.
authors.affiliation: Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. mistryr@email.chop.edu
authors.forename: Rakesh D
authors.initials: RD
authors.lastname: Mistry
authors.forename: Christine S
authors.initials: CS
authors.lastname: Cho
authors.forename: Warren B
authors.initials: WB
authors.lastname: Bilker
authors.forename: David C
authors.initials: DC
authors.lastname: Brousseau
authors.forename: Evaline A
authors.initials: EA
authors.lastname: Alessandrini
mesh_terms: D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007232:Infant, Newborn, Diseases / Q000145:classification* / Q000175:diagnosis; D038801:International Classification of Diseases; D008297:Male; D008499:Medical Records; D015337:Multicenter Studies as Topic; D012720:Severity of Illness Index; D014218:Triage