Most non-urgent emergency room visits appropriate

Not only are the majority (86 percent) of walk-in visits to hospital emergency departments appropriate, but one in 20 patients who are initially felt to be "non-urgent" actually requires admittance to the hospital after a complete evaluation, reported researchers from Emory, the University of California at San Francisco and others, in the Aug. 13 issue of the Journal of the American Medical Association.

"Since ED (emergency department) visits generate higher charges than comparable visits to physicians, `inappropriate' use of the ED has been cited as an important contributor to the increasing cost of health care," the authors wrote. "This observation has prompted a number of state governments and managed care organizations to implement strategies to discourage non-urgent ED visits. However, some programs have been implemented without a clear understanding of the reasons patients use the ED for non-urgent problems. Surveys suggest that lack of access to care is a major problem and that many patients face both financial and non-financial barriers to care outside the ED. Since most of these studies are dated or based on information from a single institution, the generalizability of these findings is unclear. To clarify the reasons for ambulatory visits to EDs, we conducted a multicenter study at 56 hospitals across the United States."

The team evaluated data on 6,187 patients visiting those 56 hospitals during a 24-hour period beginning 7 a.m., June 15, 1994. Patients arriving by ambulance were excluded from the analysis.

"A total of 5,323 patients (86 percent) had clinical reasons or preferences for seeking care at an ED, including 2,799 (45 percent) who thought they had an emergency or an urgent condition or were too sick to go elsewhere," reports study co-author Arthur Kellermann, director of the Division of Emergency Medicine, Department of Surgery. "Nineteen percent (1,199) reported that they were sent to the ED by a health care professional. Patients with a regular clinician or with insurance cited similar reasons for seeking care at an ED.

"A total of 3,062 patients (50 percent) cited one or more non-financial barriers to care as an important reason for coming to the ED, and 949 (15 percent) cited financial considerations. A total of 3,045 patients (49 percent of ambulatory patients and 37 percent of total ED visits) were assessed at triage as having a non-urgent condition; 166 of them (5.5 percent) were admitted to the hospital. We found few differences between non-urgent patients who were routed away from the ED by the triage nurses and `non-urgent' patients who were admitted to the hospital."

According to Kellermann, so-called "convenience shopping" of EDs constituted only a small percentage of the study participants' reasons for visiting an ED. "Most people came for appropriate reasons," Kellermann said. "They were sick, hurt or scared."

"We must be careful about `telephone triage' and use of off-site `gatekeepers' to restrict access to emergency care. It is virtually impossible to safely tell urgent from non-urgent patients without a proper physical examination."

Authors of the JAMA paper also include (first author) Gary P. Young,

Jack Ellis, and Doug Bouley, of the Department of Emergency Medicine, Highland General Hospital, Oakland, Calif., and the University of California at San Francisco; and Michele B. Wagner, Division of Emergency Medicine, Beth Israel Hospital, Boston.

Kellermann also directs the Center for Injury Control at the Rollins School of Public Health.

--Lorri Preston

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