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Next-Day Care for Emergency Department Users with Nonacute Conditions: A Randomized, Controlled Trial

Donna L. Washington, MD, MPH; Carl D. Stevens, MD, MPH; Paul G. Shekelle, MD, PhD; Philip L. Henneman, MD; and Robert H. Brook, MD, ScD
[+] Article, Author, and Disclosure Information

From Veterans Affairs Greater Los Angeles Healthcare System and University of California, Los Angeles, Los Angeles, California; Harbor–UCLA Medical Center, Torrance, California; and RAND Health, Santa Monica, California; Baystate Medical Center, Springfield, Massachusetts, and Tufts University School of Medicine, Boston, Massachusetts.

Disclaimer: The views expressed in this article are solely those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation.

Acknowledgments: The authors thank the emergency department nurses at Harbor–UCLA Medical Center for their assistance throughout the study. They also thank Martin Lee, PhD, for assistance with statistical analysis and Rachel Louie for programming support.

Grant Support: By the Robert Wood Johnson Foundation (no. 030807). Dr. Washington was a Robert Wood Johnson Foundation Minority Medical Faculty Development Program fellow at the time of the study and is currently a Research Associate of the Veterans Affairs Health Services Research and Development Service. Dr. Shekelle was a Senior Research Associate of the Veterans Affairs Health Services Research and Development Service.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Donna L. Washington, MD, MPH, Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, 111G, Los Angeles, CA 90073; e-mail, donna.washington@med.va.gov.

Current Author Addresses: Drs. Washington and Shekelle: Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, 111G, Los Angeles, CA 90073.

Dr. Stevens: Department of Emergency Medicine, Harbor–UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90502.

Dr. Henneman: Department of Emergency Medicine, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199.

Dr. Brook: RAND Health, 1700 Main Street, Santa Monica, CA 90407.

Author Contributions: Conception and design: D.L. Washington, C.D. Stevens, P.L. Henneman, R.H. Brook.

Analysis and interpretation of the data: D.L. Washington, C.D. Stevens, P.G. Shekelle, P.L. Henneman, R.H. Brook.

Drafting of the article: D.L. Washington, P.G. Shekelle.

Critical revision of the article for important intellectual content: D.L. Washington, C.D. Stevens, P.G. Shekelle, P.L. Henneman, R.H. Brook.

Final approval of the article: D.L. Washington, C.D. Stevens, P.G. Shekelle, P.L. Henneman, R.H. Brook.

Provision of study materials or patients: D.L. Washington, P.L. Henneman.

Statistical expertise: D.L. Washington, P.G. Shekelle.

Obtaining of funding: D.L. Washington.

Administrative, technical, or logistic support: D.L. Washington, C.D. Stevens, P.G. Shekelle, P.L. Henneman, R.H. Brook.

Collection and assembly of data: D.L. Washington.

Ann Intern Med. 2002;137(9):707-714. doi:10.7326/0003-4819-137-9-200211050-00005
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We used explicit clinical criteria to identify persons using public hospital emergency departments who were at low risk for adverse outcomes from deferred care. Our study is one of relatively few that evaluates the safety of explicit deferred care guidelines, and it is one of the first to use a randomized, controlled design. Our finding that 36% of screened patients met deferred care guidelines was consistent with published estimates that 40% to 55% of all emergency department visits are for nonemergency conditions (1, 20, 25). Published studies also show, however, that identifying such conditions is difficult, and incorrect triage rates of up to 5.5% have been noted (26). For patients in our study, deferred care was not associated with clinically important deficits in health status or access to care. Implicit criteria used by triage nurses to classify patients vary from hospital to hospital, shift to shift, and even nurse to nurse (26). In contrast, studies of computerized triage algorithms in military settings found an incorrect triage rate of 1.2% when algorithms were used by non–health care personnel (12). Our study used explicit standardized algorithms administered by experienced emergency department nurses.

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Figure 1.
Sore throat data form.Jt Comm J Qual Improve.

© Washington DL, Shekelle PG, Stevens CD: “Does this patient need to be evaluated today? Designing a guideline-driven triage process to determine the timing of care for adults with respiratory infection symptoms.” 2000;26:87-100. Reprinted with permission. BP = blood pressure; DBP = diastolic blood pressure; SBP = systolic blood pressure.

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Figure 2.
Flow of patients in the trial.

*Only patients with chief symptoms for which deferred care criteria exist were screened. †Patients were excluded if they were younger than 18 years of age, were taken immediately to the emergency department treatment area, were women in active labor, did not speak English or Spanish, were participating in another active study, had no access to a telephone or pager for follow-up, declined to give informed consent, or required more detailed evaluation. RN = registered nurse.

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Summary for Patients

Deferring Emergency Room Care

The summary below is from the full report titled “Next-Day Care for Emergency Department Users with Nonacute Conditions. A Randomized, Controlled Trial.” It is in the 5 November 2002 issue of Annals of Internal Medicine (volume 137, pages 707-714). The authors are DL Washington, CD Stevens, PG Shekelle, PL Henneman, and RH Brook.


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