ED visits are usually for emergencies rather than ‘primary care’

Use of presenting complaint is ineffective in determining whether emergency department (ED) visits could have been treated by a primary care visit instead, a recent study found.

Efforts to optimize utilization of emergency care resources have focused on identifying patients presenting to EDs who might be appropriately evaluated and treated in other settings, such as primary care clinics. To determine whether patients who could have been treated in a primary care setting could have been identified on initial triage in the ED, researchers modified an established algorithm used to classify ED discharge diagnoses into those that needed emergency care and those that might have been appropriately treated in a primary care setting. The algorithm was then applied to nearly 35,000 records in the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS), with each representing a unique ED visit.

For the visits with discharge diagnoses considered primary care-treatable conditions, the presenting complaints at triage were compiled into a list of “non-emergent complaints.” The data set was then reexamined, and all visits with “non-emergent” chief complaints at triage were reviewed to assess whether the presenting complaint could be used to identify patients with primary care-treatable conditions. Results appeared in the March 20 Journal of the American Medical Association.

The study found that discharge diagnoses were not easily determined by evaluating the presenting complaints. The primary care-treatable patients (who made up 6.3% [95% CI, 5.8% to 6.7%] of the total ED population) presented with the same complaints seen for 88.7% (95% CI, 88.1% to 89.4%) of all ED visits.

Of the patients with non-emergent complaints, a total of 11.1% (95% CI, 9.3% to 13.0%) of these visits were identified at triage as needing immediate or emergency care, and 12.5% (95% CI, 11.8% to 14.3%) required hospital admission. Among admitted patients, 11.2% (95% CI, 9.5% to 12.9%) went to a critical care unit, 22.9% (95% CI, 18.4% to 27.4%) required step-down or telemetry monitoring, 3.4% (95% CI, 2.5% to 4.3%) required the operating room, and 7.0% (95% CI, 5.7% to 8.4%) were admitted to an observation unit.

Also, 3.7% (95% CI, 3.4% to 4.1%) of these patients had been seen in the same ED within the last 72 hours, and 2.1% (95% CI, 1.7% to 2.5%) had been discharged from a hospital within the past seven days.

Further complicating matters was that 79.7% patients (95% CI, 78.2% to 81.3%) had at least one abnormal triage vital sign recorded:

• respiratory rate (61.8%; 95% CI, 59.9% to 63.8%),
• blood pressure (34.2%; 95% CI, 32.7% to 35.8%),
• abnormal heart rate (21.8%; 95% CI, 20.8% to 22.8%)
• hypoxia (6.6%; 95% CI, 5.3% to 7.9%), or
• hypo- or hyperthermia (6.1%; 95% CI, 5.5% to 6.7).

Thus, it may not be possible, based on presenting complaints, to accurately identify emergency visits that could have been treated by primary care instead in order to limit or deny payments for these visits, the researchers concluded.

The researchers wrote, “Attempting to discourage patients from using the ED based on the likelihood that they would have nonemergency diagnoses risks sending away patients who require emergency care. The majority of Medicaid patients, who stand to be disproportionately affected by such policies, visit the ED for urgent or more serious problems.”