Safety of referral of patients with non-urgent conditions from the emergency room to primary care centers

Seguridad en urgencias sobre la referencia de pacientes no urgentes a centros de atención primaria

Objectives: to determine the safety of referral of triage category 4 and 5 patients from the emergency room to primary care centers, aware of their final disposition and the potential complications of this strategy. Methods: a retrospective observational study of 333 triage category 4 and 5 patients who were referred from the emergency room to a primary care center in February 2019. Information on scheduled appointment attendance, and final consultation diagnosis was obtained from the insurer. Results: 52 patients (15.6%) failed to attend their scheduled appointment presenting no health complications. Of the 281 who attended their clinic appointment, 1.4% were referred for urgent specialist consultation without requiring hospital admission. The primary care physician provided care and management to 98.6% of studied patients on an outpatient basis. Differences were found among those failing to attend primary care in the 3 to 17 (p=0.009) and 18 to 37 years (p=0.04) age subgroups. Conclusions: triage category 4 and 5 patients referral strategy from the emergency service to primary care centers is safe, even if patients fail to attend their scheduled appointment.

1. Resolución 5593. Por la cual se fija el valor de la Unidad de Pago por Capitación (UPC) para la cobertura del Plan Obligatorio de Salud de los Regímenes Contributivo y Subsidiado para la vigencia 2016 y se dictan otras disposiciones. Diario Oficial 49.739 (28 diciembre 2015).
2. Estrada-Atehortúa AF, Zuluaga-Gómez M. Estrategias para la medición y el manejo de la sobreocupación de los servicios de urgencias de adultos en instituciones de alta complejidad con altos volúmenes de consulta. Revisión de la literatura. Iatreia. 2020;33(1):68-77. https://doi.org/10.17533/udea.iatreia.34.
3. Vargas-Lorenzo I, Vázquez-Navarrete ML, Mogollón-Pérez AS. Acceso a la atención en salud en Colombia. Rev Salud Pública. 2010;12(5):701-712.
4. Kelen GD, Wolfe R, D’Onofrio G, Mills AM, et al. Emergency department crowding: the canary in the health care system. NEJM Catalyst. 2021. https://doi.org/10.1056/CAT.21.0217.
5. Jo S, Jeong T, Jin YH, Lee JB, Yoon J, Park B. ED crowding is associated with inpatient mortality among critically ill patients admitted via the ED: post hoc analysis from a retrospective study. Am J Emerg Med. 2015;33(12):1725-31. https://doi.org/10.1016/j.ajem.2015.08.004.
6. Shanafelt TD, West CP, Sinsky C, Trockel M, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc. 2019;94(9):1681-1694. https://doi.org/10.1016/j.mayocp.2018.10.023.
7. Lindner G, Woitok BK. Emergency department overcrowding: Analysis and strategies to manage an international phenomenon. Wien Klin Wochenschr. 2021;133(5-6):229-233. https://doi.org/10.1007/s00508-019-01596-7.
8. Bentley JA, Thakore S, Morrison W, et al. Emergency department redirection to primary care: a prospective evaluation of practice. Scott Med J. 2017; 62(1):2–10. https://doi.org/10.1177/0036933017691675.
9. O'Keeffe C, Mason S, Jacques R, Nicholl J. Characterising non-urgent users of the emergency department (ED): A retrospective analysis of routine ED data. PLoS One. 2018;13(2):e0192855. https://doi.org/10.1371/journal.pone.0192855.
10. Chmiel C, Wang M, Sidler P, Eichler K, Rosemann T, Senn O. Implementation of a hospital-integrated general practice—a successful way to reduce the burden of inappropriate emergencydepartment use. Swiss Med Wkly. 2016;10;146:w1428. https://doi.org/10.4414/smw.2016.14284.
11. Clement N, Businger A, Martinolli L, Zimmermann H, Exadaktylos A. Referral practice among Swiss and non-Swiss walk-in patients in an urban surgical emergency department. Swiss Med Wkly. 2010;140:w13089. https://doi.org/10.4414/smw.2010.13089.
12. Ghazali DA, Richard A, Chaudet A, Choquet C, Guericolas M, Casalino E. Profile and Motivation of Patients Consulting in Emergency Departments While not Requiring Such a Level of Care. Int J Environ Res Public Health. 2019;16(22):4431. https://doi.org/10.3390/ijerph16224431.
13. Payne K, Dutton T, Weal K, Earle M, Wilson R, Bailey J. An after hours gp clinic in regional Australia: appropriateness of presentations and impact on local emergency department presentations. BMC Fam Pract. 2017;18(1):86. https://doi.org/10.1186/s12875-017-0657-6.
14. Morin C, Choukroun J, Callahan JC. Safety and efficiency of a redirection procedure toward an out of hours general practice before admission to an emergency department, an observational study. BMC Emerg Med. 2018;18(1):26. https://doi.org/10.1186/s12873-018-0173-6.
15. Unwin M, Crisp E, Rigby S, Kinsman L. Investigating the referral of patients with non-urgent conditions to a regional Australian emergency department: a study protocol. BMC Health Serv Res. 2018 Aug 20;18(1):647. https://doi.org/10.1186/s12913-018-3411-4.
16. Erazo Castro PA, Sánchez Granada CC. Impacto del Centro Integrado de Gestión del Acceso en Salud (CIGA) en el servicio de urgencias de la clínica León XIII [Trabajo de grado]. Medellín, Colombia: Universidad de Antioquia; 2018.
17. Whittaker W, Anselmi L, Kristensen SR, et al. Associations between extending access to primary care and emergency department visits: a difference-in-differences analysis. PLoS Med. 2016;13(9):e1002113. https://doi.org/10.1371/journal.pmed.1002113.
18. Hysenbegasi M, Hubloue I, Vanobberghen R, Kartounian J, Devroey D. Evolution over 11 years of the characteristics of walk-in patients at the emergency department of a university hospital in Brussels. J Med Life. 2019;12(1):34-42. https://doi.org/10.25122/jml-2018-0053.
19. Centers for Disease Control and Prevention. National hospital ambulatory medical care survey: 2016 emergency department summary tables. National Center for Health Statistics; 2017 (citado octubre 6 2021). Disponible en: https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf
20. Idil H, Kilic TY, Toker İ, Dura Turan K, Yesilaras M. Non-urgent adult patients in the emergency department: Causes and patient characteristics. Turk J Emerg Med. 2018;18(2):71-74. https://doi.org/10.1016/j.tjem.2017.10.002.
21. Andrews H, Kass L. Non-urgent use of emergency departments: populations most likely to overestimate illness severity. Intern Emerg Med. 2018;13(6):893-900. https://doi.org/10.1007/s11739-018-1792-3.
22. Al-Otmy SS, Abduljabbar AZ, Al-Raddadi RM, Farahat F. Factors associated with non-urgent visits to the emergency department in a tertiary care centre, western Saudi Arabia: cross-sectional study. BMJ Open. 2020;10(10):e035951. https://doi.org/10.1136/bmjopen-2019-035951.
23. Akpinar Y, Demirci H, Budak E, Baran AK, Candar A, Ocakoglu G. Why do patients with minor complaints choose emergency departments and does satisfaction with primary care services influence their decisions?. Prim Health Care Res Dev. 2018;19(4):398-406. https://doi.org/10.1017/S1463423617000822.
24. Jimenez MLC, Manzanera R, Carascal MB, et al. Factors affecting the non-urgent consultations in the emergency department of a tertiary hospital in the Philippines: A cross-sectional study. Emerg Med Australas. 2021;33(2):349-356. https://doi.org/10.1111/1742-6723.13725.
25. Coster JE, Turner JK, Bradbury D, Cantrell A. Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis. Acad Emerg Med. 2017;24(9):1137-1149. https://doi.org/10.1111/acem.13220.
26. Young GP, Wagner MB, Kellermann AL, Ellis J, Bouley D. Ambulatory visits to hospital emergency departments. Patterns and reasons for use. 24 Hours in the ED Study Group. JAMA. 1996;276(6):460-465. https://doi.org/10.1001/jama.276.6.460.
27. Tammes P, Morris RW, Brangan E, et al. Exploring the relationship between general practice characteristics and attendance at Walkin Centres, Minor Injuries Units and Emergency Departments in England 2009/10-2012/2013: a longitudinal study. BMC Health Serv Res. 2017;17(1):546. https://doi.org/10.1186/s12913-017-2483-x.
28. Vogel JA, Rising KL, Jones J, Bowden ML, Ginde AA, Havranek EP. Reasons Patients Choose the Emergency Department over Primary Care: a Qualitative Metasynthesis. J Gen Intern Med. 2019;34(11):2610-2619. https://doi.org/10.1007/s11606-019-05128-x.for acute Achilles tendon ruptures: The Leicester Achilles Management Protocol (LAMP). Injury. 2019 Apr;50(4):995-999.