Deferred Care for Patients in the Emergency Department

Many areas of the United States are characterized by widespread crowding of emergency departments. In this issue, Washington and colleagues (1) describe a randomized, controlled trial of a system designed to identify persons who have symptoms related to abdominal and pelvic pain, musculoskeletal pain, or respiratory infection and meet criteria for deferred care. After screening by an experienced emergency department nurse, patients who met criteria for deferred care received, at random, either traditional same-day care through the emergency department or an appointment at a primary care clinic at the study site the following day. Not surprisingly, the wait time was approximately twice as long for persons who consented to participate in the study than for nonparticipants. Overall, at 1-week follow-up, the patients in the deferred care group did not seem to suffer any clinically important disadvantages. Nonetheless, the trend in self-reported improvement, bed days, and disability favored the patients receiving traditional care. Washington and colleagues correctly observe that an explicit deferred care strategy, if the safety of such an approach is validated, would be safer than the current system, in which triage by waiting time sometimes results in seriously ill patients leaving emergency departments without being seen. An effective triage system involving deferred care is probably one of several attractive solutions to the desperate overcrowding and chaos seen in emergency departments in many cities throughout the United States (2).

How did we arrive at a situation in which emergency departments are forced to develop triage systems that incorporate deferred care? I suspect almost no patients would …