Next-Day Care for Emergency Department Users with Nonacute Conditions

A Randomized, Controlled Trial

5 November 2002 | Volume 137 Issue 9 | Pages 707-714

Background: Because of overcrowding and cost-control efforts, emergency departments are under pressure to refer patients with nonacute conditions to other settings. However, no validated systematic methods exist for safely performing such referrals.

Objective: To determine the effects on health status and access to care of systematically referring patients with nonacute conditions to next-day primary care.

Design: Randomized, controlled trial.

Setting: An emergency department in a public hospital.

Patients: 156 adults who used the emergency department on weekdays from 7:00 a.m. to 3:00 p.m. and met criteria for deferred care. The criteria applied to three symptom complexes that account for 33% of U.S. emergency department visits by adults.

Intervention: Next-day care at the study site's primary care center or usual same-day care.

Measurements: Self-reported health status and use of health services during 1-week follow-up.

Results: Patients assigned to next-day care did not demonstrate clinically important disadvantages in health status or physician visits compared with usual care patients. In each group, more than 95% of patients were evaluated at least once by a physician, 4% sought health services after their initial evaluation, and no patients were hospitalized or died. At follow-up, both groups reported improved health status and fewer days in bed or with disability, although the deferred care group reported less improvement on all three measures. The 95% CIs were sufficiently narrow to exclude a clinically significant difference in self-reported health status. However, the possibility of 1 additional day in bed or with disability in the deferred care group could not be excluded.

Conclusions: Clinically detailed standardized screening criteria can safely identify patients at public hospital emergency departments for referral to next-day care. However, larger studies are needed to assess the possibility of adverse effects.

Editors' Notes Context Emergency departments provide care for many walk-in patients with nonacute conditions. Safe methods for diverting such patients to alternative care sites could reduce overcrowding at emergency departments. Contribution This trial from an inner-city public hospital randomly assigned 156 adult walk-in patients to deferred next-day clinic care or usual same-day emergency department care. After 1 week, patients who received deferred care reported slightly less improvement in health status and slightly worse function than patients who received usual care. All patients improved, and none died or were hospitalized. Implications We now need larger trials in diverse populations to better define the harms and benefits of deferred care for patients who present to the emergency department with nonacute conditions. –The Editors

 

Author and Article 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{at}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.