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Despite Popular Opinion, Most ED Patients Belong in the ED

Shaw, Gina

doi: 10.1097/01.EEM.0000484512.25746.24

    ‘ED patients belong in the ED.’ That conclusion may seem pretty self-explanatory to emergency physicians, but it has been a bone of contention in the public discussion of emergency medicine — the idea that people with relatively minor complaints like earaches, coughs, and minor back pain are filling crowded emergency departments and taking time and resources away from patients who truly need emergency care.

    Now, two new studies confirm what EPs probably already know. Some exceptions aside, people who come to the emergency department do so because they are pretty sure they need to be there.

    A team of researchers from the Cleveland Clinic reported in one study that nearly half (47%) of a group of 672 patients who visited their ED during business hours in June 2014 had contacted a health care provider prior to their visit. A total of 202 of those patients (83%) had been referred to the ED. Even among those who did not actually have their own primary care provider, approximately one-third contacted a health care provider before their visit. (Ann Emerg Med 2015;66[4]:S13.)

    The ED is Fair Game

    “Despite popular sentiment to the contrary, many ED patients — with and without a primary care provider — attempt to use available resources prior to ED presentation,” said lead author Baruch Fertel, MD, an assistant professor of medicine in the department of emergency medicine at the Cleveland Clinic Lerner College of Medicine. “ED patients belong in the ED.”

    Researchers at Maine Medical Center saw similar findings in a pediatric population. The hospital enrolled 391 patients in a one-month study of referral patterns to an academic, tertiary care ED. A primary care provider referred about 43 percent of patients to the ED. (Ann Emerg Med 2014;64[4S]:S34.)

    Both of these figures are significantly higher than some previous estimates, such as the 2011 CDC survey that found only about one in five ED patients said they were there “because the doctor told them to go.” (

    Acuity was higher for provider-referred patients in both studies, and 95 percent of those patients at the Cleveland Clinic had an emergency severity index (ESI) of 2 or 3. But even among self-referred patients, 74 percent had an ESI of 2 or 3. Researchers of the Maine Medical Center study found that acuity was higher for referred patients, and that referred patients were more likely to be admitted (P=0.001 for both).

    The ED Stigma

    “There continues to be this misconception that people come to the emergency department for bumps and bruises and earaches. Those situations do exist, as any ED physician knows, but our work shows that a great deal of patients did the right thing. They came to the ED because it was the most appropriate venue for their care,” Dr. Fertel said.

    He also said their findings demonstrate that most patients are not using the ED as a substitute for primary health care. Seventy-three percent of the patients who had a primary care provider were referred by that provider to the emergency department, and 68 percent who self-referred had seen a health care provider within the previous three months.

    About 17 percent of patients (40/242) who reported speaking to a health care provider prior to their visit said they had not been referred to the ED, but chose to come in anyway. A not insignificant chunk of those — 12 of the 40 (30%) — ended up being admitted to the hospital as a result of their ED visit.

    “I don't know what's considered a reasonable mis-triage rate over the phone — patients would want it to be zero, but we know that it can't be,” Dr. Fertel said. “But this speaks to the age-old adage that people usually know when something's wrong with them. There were not a lot of these patients, but it tells us that talking to someone on the phone is not always going to substitute for an in-person evaluation of the patient.”

    The fact that both studies indicate ED patients with a health care provider referral tend to be sicker and have more of a chance of being admitted suggests that emergency physicians should evaluate those patients with a greater degree of caution, according to Dr. Fertel. “If you're sending one of those patients home, it would probably behoove you to have a little more careful discussion and close the loop with the practitioner who sent them in.”

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