Underestimation of case severity by emergency department patients: Implications for managed care

The objective was to examine differences in symptom severity assessment by emergency department (ED) patients and by emergency physicians (EPs) and to relate these assessments with case management and disposition. The design was prospective convenience sample of ED patients. The setting was a U.S. u niversity hospital ED with an annual ED patient census 28,000, The particip ants were all ED patients registered when first author was in ED; excluded were patients treated by the major trauma response team and those with a ps ychiatric chief complaint. All patients were interviewed by the first autho r and asked to classify their symptoms as emergent, urgent, or nonurgent; t he EP attending classed patients' symptoms at presentation and after work-u p was complete, Three hundred-one cases were entered in the study from May to August 1996. although 28% of ED patients self-rated their symptoms as no nurgent, 5% of this group required hospital admission, Of this group 35% we re assessed by the EP attending as having required emergent or urgent ED ca re. Of this group 5% also rated by the EP initially as nonurgent had their case severity upgraded after work up. Reliance on either patient symptom se lf-assessment or physician screening assessment by telephone to determine a ppropriateness of an ED visit is not reliably safe for at least 5% of prese nting patients. Even prospective ED visit severity assessment does not reli ably identify "unnecessary" ED visits, (Am J Emerg Med 2000;18:254 256. Cop yright (C) 2000 by W.B. Saunders Company).