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

Ann Emerg Med. 2000 Jul;36(1):15-22. doi: 10.1067/mem.2000.107003.


Study objective: We sought to develop and validate standardized clinical criteria to identify patients presenting to the emergency department whose care may be safely deferred to a later date in a nonemergency setting.

Methods: Using a modified Delphi process, a 17-member multidisciplinary physician panel developed explicit, standardized, deferred-care criteria. In a prospective cohort design, emergency nurses at a tertiary care Veterans Administration (VA) Medical Center, using the criteria, screened 1,187 consecutive ambulatory adult patients presenting with abdominal pain, musculoskeletal symptoms, or respiratory infection symptoms. Patients meeting deferred-care criteria were offered the option of an appointment within 1 week in the ambulatory care clinic at the study site; all other patients were offered same-day care. As outcome measures, we assessed nonelective hospitalizations for related conditions occurring within 7 days of evaluation at our facility 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 deferred care. Patients meeting deferred-care criteria experienced zero (95% confidence interval, 0% to 1.2%) related nonelective VA hospitalizations within 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 meet deferred-care criteria were hospitalized nonelectively for related conditions, 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 date in a nonemergency setting. These guidelines apply to a significant proportion of VA ED users with common ambulatory conditions. These criteria deserve testing in other ED settings.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Delphi Technique
  • Emergency Service, Hospital*
  • Female
  • Health Services Misuse
  • Health Status*
  • Hospitals, Veterans
  • Humans
  • Male
  • Middle Aged
  • Outcome and Process Assessment, Health Care
  • Patient Admission
  • Patient Care Team
  • Practice Guidelines as Topic*
  • Survival Rate
  • Triage*