Safely directing patients to appropriate levels of care: Guideline-driven triage in the emergency service

Study objective: We sought to develop and Validate standardized clinical cr iteria to identify patients presenting to the emergency department whose ca re may be safely deferred to a later date in a nonemergency setting. Methods: Using a modified Delphi process, a 17-member multidisciplinary phy sician panel developed explicit, standardized, deferred-care criteria. In a prospective cohort design, emergency nurses at a tertiary care Veterans Ad ministration (VA) Medical Center, using the criteria, screened 1,187 consec utive ambulatory adult patients presenting with abdominal pain, musculoskel etal symptoms, or respiratory infection symptoms. Patients meeting deferred -care criteria were offered the option of an appointment within 1 week in t he ambulatory care clinic at the study site; ail other patients were offere d same-day care. As outcome measures, we assessed nonelective hospitalizati ons for related conditions occurring within 7 days of evaluation at our fac ility 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 d eferred care. Patients meeting deferred-care criteria experienced zero (95% confidence interval, 0% to 1.2%) related nonelective VA hospitalizations w ithin 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 mee t deferred-care criteria were hospitalized nonelectively for related condit ions, and 5 (0.5%) died. Conclusion: 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 dale in a nonemergency setting. Thes e guidelines apply to a significant proportion of VA ED users with common a mbulatory conditions. These criteria deserve testing in other ED settings.