ORIGINAL CONTRIBUTION

Emergency Physicians' and Patients' Assessments:

Urgency of Need for Medical Care

Marilyn J. Gifford, MD Colorado Springs, Colorado

Jacek B. Franaszek, MD Geoff Gibson, PhD

Chicago, Illinois

A study was conducted under the sponsorship of the Emergency Medical Ser- vices (EMS) Committee of the American College of Emergency Physicians (ACEP) that was intended to examine prospectively patients' and physicians' perceptions of the urgency of need for medical attention. Patients presenting to the emergency departments of 24 hospitals between February 25, 1980 and March 3, 1980, were surveyed. The hospitals represented a range of geo- graphic areas and bed capacities. At each hospital a standard data collection questionnaire was supplied to every patient presenting to the emergency de- partment within the study period and a standard form was provided to the physician seeing each patient during the study period. A total of 10,253 forms (87% compliance) were returned and evaluated. Physicians' initial (prospec- tive) assessments indicated that 12.6% of patients needed attention immedi- ately (within minutes); 26.3%, urgently (within 1 to 2 hr); and 28.1%, promptly (within 2 to 12 hr). Retrospectively, reassessment by physicians indicated that 9.4% of patients needed attention immediately; 23.4%, urgently; and 29.6%, promptly. Patients' evaluations of urgency differed significantly (P<0.05): 44.4% thought tlley needed care immediately; 28.5%, urgently; and 15.6%, promptly. Physicians concurred that 70% of these patients needed care within 12 hr. Twelve percent of patients rated the urgency of their condition lower than did the physicians, and 25% of patients that the physicians rated as needing immediate attention did not recognize the need for urgent care and thought they could wait from 1 hr to days. This study indicates that patients presenting to the emergency department need care more urgently than was previously supposed. Gifford M J, Franaszek JB, Gibson G: Emergency physicians' and patients' assessments: urgency of need for medical care. Ann Emerg Med 9: 502-507, October 1980. American College of Emergency Physicians, patient urgency study; assessment of need for care, emergency department, prospective and retrospective; assessment of need for care, emergency department, patient and physician; patient urgency study, American College of Emergency Physicians

From the Emergency Medical Services Committee, American College of Emergency Physi- cians, Dallas, Texas. Presented at the University Association for Emergency Medicine Annual Meeting in Tucson, Arizona, April 1980. Address for reprints: EMS Committee, American College of Emergency Physicians, PO Box 61911, Dallas, Texas 75261.

9"10 (October) 1980 Ann Emerg Med 502/9

I N T R O D U C T I O N

The term <<emergency" is diffi- cult to define. As Wolcott 1 has indi- cated, patients, physicians, and socie- ty in general have varying concepts of what constitutes an emergency. In some cases these definitions overlap (Figure 1); very often they do not.

Patient utilization of the emer- gency department quite clearly relates to the patient's perception of whether or not an "emergency" exists, but the proportion of emergency department visits viewed as true emergencies by the emergency physician is unclear. Also ill-defined are the extent to which the physician's initial percep-

tion of urgency is altered by a more thorough assessment and formulation of a diagnosis, and the degree to which physician and pat ient opinions of urgency correlate.

Previous patient urgency studies had been based on retrospective re- views of patient charts, and many had confused or attempted to judge concurrently the urgency of a situa- tion with its severity. Members of the ACEP Board of Directors and the EMS Committee had the impres- sion that such a study design was not valid. The EMS Committee was charged by the Board of Directors in the fall of 1979 to conduct a prospec- tive study of patient and physician

Fig. 1. Patients, physicians, and soci- ety in general have varying concepts of what constitutes an emergency, sometimes these definitions overlap but frequently they do not. (Fron Wolcott BW, 8.'242, 1979.)

FEBRUARY 2Z 1980 AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

EMERGENCY DEPARTMENT UTILIZATION DATA COLLECTION FORM

IDENTIFICATION NO, 237147 @

ALL INFORMATION CONFIDENTIAL

PART I: To be answered by patient. Answers will not influence order of treatment in the emergency department.

1. T i m e : _ 8:00AM - 4:00PM (day) 2. S e x : _ female 4:00PM - 12:00AM (evening) _ _ male

_ _ 12:00AM - 8:00AM (night) (~) ©

3. Age: (eg, 35 years old = o 3 5 _)

@ 4. Arrived at the emergency department:

.bus car taxi ,_,.,.,.,.,.,.,.,.,~_ a m b u I a n c e police walked other y l j

5. Briefly say what problem, fS-f example, headache, made you come to the emergency department.

6. From this moment, for your condition, do you think you need care: immediately (within minutes) urgently (within 1-2 hours)

(~) promptly (within 2-12 hours) soon (within 24 hours)

_ _ fairly soon (within days)

7. Do you have your own doctor or clinic? _ _ yes _ _ no ®

8. Why did you choose to come to thi__s emergency department?

you had a scheduled appointment ( ~ _ _ your doctor instructed you to come

you could not get an office or clinic appointment you were recalled you had an emergency problem other

Fig. 2. Data collection form used by patients.

lO/503 Ann Emerg Med 9:10 (October) 1980

perception of urgency among those patients presenting to the emergency department. This communication re-

I ports the results of tha t study.

MATERIALS A N D M E T H O D S

A prospective investigation was undertaken within six hospitals in each of four geographic areas of the United States comprising the east, south, west, and midwest. In each area, two of the hospi tals were in urban, suburban, and rural settings. In each area and in each hospital a physician coordinator participated in assembling the data and in assuring the strict cooperat ion needed from the physicians, patients, and hospi- tals. This cooperation required that patients complete a s tandard ques- ti0nnaire upon en te r ing the emer- gency department and that physicians complete a standard form which hs- sessed prospectively and retrospective- Iy the physicians' impressions of the urgency of the visits. A comparison was made of the degree to which there

was c o r r e s p o n d e n c e b e t w e e n the physicians' and the patients' percep- tions.

The retrospective assessment fol- lowed the e s t a b l i s h m e n t of a dis- charge diagnosis and was compared with the original physicians' and pa- tients' perceptions after the outcome of the emergency depar tmen t visit was known. Among other data being sought was an evaluat ion of trans- portation methods used by patients who presented for emergency care.

As a crosscheck, a comparison was made be tween the n u m b e r of data collection forms completed and the emergency depar tments ' log to- tals. Data were collected on prenum- bered forms which had been attached to the pat ient records. The pat ient portion (Figure 2) and the physician port ion (Figure 3) of the form are shown.

The questionnaire sought demo- graphic da ta and ident i f icat ion by the pa t i en t of the chief compla in t and an estimate of the time in which

the individual should be seen. Pa- t ients were informed tha t their re- sponses would -have no bear ing on the actual order of service. The pa- t ient portion of the form was com- pleted by the pat ient or by a clerk who recorded the patient 's responses if the patient could not do so.

The physician portion indicated the discharge diagnosis and disposi- tion, and an estimate of the urgency of need for care. The physician was asked to enter his pre l iminary im- pression before thorough examina- tion (prospective impression) and to indicate his impression after a di- agnosis and disposition had been de- t e rmined (retrospective). For both the physicians and the patients the urgency categories comprised:

• Immediate (within minutes); • Urgent Cwithin 1 to 2 hr); • Prompt (within 2 to 12 hr); • Soon (within 24 hr); and • Fairly soon (within days).

An additional category was available to the physicians: ~did not need med-

PART I1: To be answered by physician.

1. When you first saw this patient, before you did a detailed assessment, you felt that attention was required:

_ _ immediately (within minutes) urgently (within 1-2 hours)

Q promptly (within 2-12 hours) soon (within 24 hours) fairly soon (within days) did not need medical attention

2. What was the discharge diagnosis relative to the chief complaint?

3. Was the patient: admitted expired in ED ( ~ discharged left against advice

_ _ transferred _ _ left without being seen

4. Retrospectively, after the patient left or a diagnosis was established, you felt the problem merited attention:

_ _ immediately (within minutes) urgently (within 1-2 hours)

_ _ promptly (within 2-12 hours) (~) soon (within 24 hours)

fairly soon (within days) did not need medical attention

5. In your estimation, this patient could have been treated adequately:

_ _ o n l y in the ED _ _ in a hospital clinic

( ~ _ _ in a doctor's office _ _ at home

other

6. If you chose an alternative to the emergency department (question #5), was it available to the patient within the time it took to arrange a disposition?

_ _ yes

O _ _ no

_ _ don't know

Fig. 3. Data collection form used by physicians.

9:10 (October) 1 9 8 0 A n n E m e r g M e d 504 /11

ical attention." All unconscious pa- tients were assumed to have rated the urgency of their condition as 'rim- mediate."

RESULTS Among 11,823 patients seen in

the 24 emergency departments dur- ing the study period (as determined from log totals), data were collected for 10,253 encounters (87%). Of the questionnaires, 80.5% had complete patient and physician urgency rat- ings. The physicians' determination of urgency is shown (Table 1, Figures 4 and 5). For analytic convenience, those categories for which medical care was deemed to be unnecessary before 12 hr were combined under the term ~'delayed." These categories comprised %oon," ~fairly soon," and ~not needed." Physicians' prospective impressions indicated that: 12.6% of patients needed attention immedi- ately (within min); 26.3% of patients were in the urgent category (within 1 hr to 2 hr); and 28.1% of patients were in the prompt category (within 2 hr to 12 hr). An additional 33% of patients could have waited more than 12 hr for care.

The retrospective judgment by physicians indicated that: 9.4% of pa- tients needed attention immediately; 23.4% of patients were in the urgent category; and 29.6% of patients were in the prompt category. The remain- ing 37.6% of pat ients could have waited more than 12 hr for care.

Cumulatively, the need for care as judged prospectively by physicians indicated that 67.0% of patients were judged to require attention within 12 hr. Of this group, 18.8% required im- mediate attention. Physicians' retro- spective (post-care) reassessment was that 62.4% of patients required atten- tion within 12 hr. Of this group, 15.1% required immediate attention.

A summary of the patients' opin- ions of the urgency of their need for care, indicating that 88.5% believed they needed attention within 12 hr, is shown (Table 2).

The comparison of physicians' and patients' responses is summa- rized (Tables 3 and 4). In those in- stances in which physicians indicated that the need was for immedia te attention, 75.2% of pat ients inde- pendently reached the same conclu- sion. However, in those instances in which patients indicated a need for immediate attention, physicians in- dependently agreed in 20.7% of cases (Table 4).

Table 1 PHYSICIANS' PROSPECTIVE AND

RETROSPECTIVE ANALYSIS OF URGENCY

Prospective Retrospective

Immediately Urgently Promptly No. (%) No. (%) No. (%)

1,127 (12.6) 2,360 (26.3) 2,522 (28.1) 843 (9.4) 2,098 (23.4) 2,655 (29.6)

Delayed NO. (%)

2,968 (33.0) 3,381 (37.6)

o~

40

35

30

25

20

15

10

5

38.9

< 2 h r

28.1

2-i2 hr

33.0

> 12 hr

Fig. 4. Prospective analysis by physician.

40

35

30

25

20

15

10

5

32.8

29.6

37.6

< 2 h r 2-12 hr > 12 hr

Fig. 5. Retrospective analysis by physician.

12/505 Ann Emerg Med 9:10 (October) 1980

DISCUSSION This study represents an initial

overview and report on a prospective investigation of the comparison of emergency physicians' and patients' assessments of the urgency of need for medical care conducted by the ACEP EMS Committee. Further re- ports will address diagnostic, demo- graphic, and prehospi ta l /hospi ta l emergency medical services data.

This investigation is believed to be the only study that has attempted to define in a prospective manner the emergency nature or appropriateness 0fpatient visits to emergency depart- ments. It is believed that these data are functionally important in that patients' need for care determined in this investigation appeared more ur- gent prospectively when compared with their need retrospectively. It is to be anticipated that fewer patients prospectively deemed to require care immediately would fall into the same category after the diagnostic process was completed. As an example, an individual presenting with a com- plaint of precordial chest pain might well appear to require care within minutes. However, after the appro- priate evaluation was completed, and the diagnosis of chest wall syndrome arrived at, the retrospective judg- ment of immediacy of need for care would be less than that prospectively.

The anecdotal rendering of emer- gency department experiences has in- dicated that 5% of patients' problems were ~'critical," 15% ~emergency," and 80% "non-emergency." Retrospective studies conducted by others (Table 5) have suggested that 30% to 81.3% of visits to emergency departments were "non-emergency." Perhaps it is pre- Jictable that the patient will consider his illness more acute than will the physician. However, 12% of patients underestimated the urgency of their condition and 24.8% in this study did not appreciate that they needed im- mediate attention (Table 3). In stark contrast to previous studies 2s and popular belief this study demonstrates that between three and four times as many patients need urgent care as has been previously reported, and that in 77% of cases in this study, the physi- eians' prospective and retrospective analyses of urgency were identical. Indeed, in 4% of cases, the physician judged the patient 's condition to be more urgent in retrospect.

It is appropriate to attempt to compare the current study with the results previously reported by others (Table 5) and to comment on those

Table 2 PATIENT OPINION OF URGENCY

(n=8,256)

Category No. % immediately 3,668 44.4 Urgently 2,350 28.5 Promptly 1,284 15.6 Delayed 954 11.5

factors which make such compari- sons somewhat invalid. The capabili- ties of emergency departments and patterns of utilization have markedly changed during the past 15 years, making comparisons with investiga- tions conducted in 19644 and 19693 questionable. All previous investiga- tions were retrospective 2s and often based on chart review. 5-7 There is marked variance in the definitions of urgency among the various studies, such that while some studies catego- rized patients according to defini- tions of urgency based closely on time- to-necessary-intervention criteria, 3-5 most relied on disease process or "threat to life and limb" as the major determinant of the emergency nature of the problem.

CONCLUSION In conclusion, among 10,253

emergency department visits studied prospectively between February 25, 1980 and March 3, 1980, almost 40% of patients were deemed to need atten- tion within 2 hr and 67.0% of patients were deemed to require at tent ion within 12 hr. Most emergency depart- ment visits in the 24 hospitals partici- pating in this study were for problems relatively urgent and non-routine. In- appropriate utilization of emergency departments appears to be more a per- ceptual issue than a real one when judged objectively.

The authors thank the following: Michael Breuer, for his enthusiasm and computa- tional ability; John McDade, MD, for his unflagging support; John Rupke, MD; Bruce Hildreth, MD; Dighton Packard, MD; Dennis Koziol, MD; Michael Vance, MD; the physician coordinators at each hospital in the study; and Carl Jelenko, III, MD, for assistance in preparation of the manuscript.

REFERENCES 1. Wolcott BW: What is an emergency? Depends on Whom you ask. JACEP 8:241- 243, 1979.

Table 3 CONCORDANCE OF PATIENT OPINION WITH PHYSICIAN INITIAL ANALYSIS OF URGENCY

(3 Most Urgent Categories) (n = 8,256)

Physician Analysis Immediately Urgently Promptly

Patient Opinion Patient Opinion Patient Opinion More Urgent (%) Same (%) Less Urgent (%)

0 (0) 760 (75.2) 250 (24.8) 1,105 (50.9) 650 (29.9) 416 (19.2) 1,665 (70.9) 458 (19.5) 228 (9.6)

Table 4 CONCORDANCE OF PHYSICIAN INITIAL

ANALYSIS WITH PATIENT OPINION

Patient Opinion Immediately Urgently Promptly

Physician Physician Analysis Analysis

More Urgent (%) Same (%) 0 (0) 760 (20.7)

167 (7.1) 850 (27.7) 333 (26.0) 458 (35.7)

Physician Analysis

Less Urgent (%) 2,908 (79.3) 1,533 (65.2)

493 (38.3)

9:10 (October) 1980 Ann Emerg Med 506/13

2. Walker LL: The emergency department - - entry point into the health care sys- tem. JACEP 4:129-132, 1975.

3. Gibson G: Emergency Medical Services in the Chicago Area. Center for Health Administration Studies, The University of Chicago, 1970.

4. Kluge DN, Wegryn RL, Lemley BR: The expanding emergency department. JAMA 191:801-805, 1965.

5. Jacobs AR, Gavett JW, Wersinger R: Emergency department utilization in the urban community: implications for com- munity ambulatory care. JAMA 216:307- 312, 1971.

6. Parker S: Emergency room utilization at Hermann Hospital. Texas Med 74:1-7, 1978.

7. Engstrom T: Emergency department encounter data, 1975-1976 Wisconsin. De-

partment of Health and Social Services, December 1977.

8. Mendenhall RC: Emergency Physician Practice Study Report. Univers i ty of Southern California School of Medicine, September 14, 1979.

9. Boyd DR, Micik SH, Lambrew CT, et al: Medical control and accountability of emergency medical services (EMS) sys- tems. IEEE Transaction on Vehicular Technology 6, November 1979.

Table 5 PATIENT URGENCY STUDIES

Study

Walker 2 (1972)

Gibson 3 (1969)

Kluge 4 (1964)

Jacobs 5 (1971)

Results (%) Method Comments

Non-emergent* Urgent Emergent

Non-emergentt Urgent Emergent

Not emergency:l: Emergency-Office Emergency-ED

33 Physician Oklahoma 56 post-treatment 662 patients 11 analysis 44% sample

C h c g S u b 50 37 Physician Chicago and 40 53 retrospective suburbs 10 10 analysis

30 Retrospective One emergency 3"5 department 35

Not emergency:l: 6 Physician/ Rochester, New York Emergency-Office 57 nurse 1% random Emergency-ED 35 retrospective sample of nine Could not code 2 chart analysis emergency

departments

Parker 6 Not emergent 81.3 Retrospective Houston (1977) Acute 14.3 chart review random sample

Emergent 4.3 of triage of 230 cases in one year

Engstrom 7 Non-urgent§ 61.5 Retrospective 1,268,086 (Wisconsin) Urgent 22.8 patients (1976) Emergent 2.8

Not available 12.8

Mendenhall a None 27.1 Retrospective One "typical" day (189 (1979) Non-urgent 33.5 questionnaire emergency visits)

Urgent 16.7 Emergency 16.8 Unavailable 5.9

*Not defined. ?Non-emergent - - Does not require the resources of an emergency service; disorder is minor or non-acute. U r g e n t - Requires medical attention within a few hours; disorder is acute but not necessarily severe; danger if not attended. E m e r g e n t - Requires immediate medical attention; disorder is acute and potentially threatens life or function; delay is harmful to patient.

:kNot Emergency - - Does not require the advice of a physician or could easily wait 24 hr or longer for attention. Emergency~Off ice - - Conditions which by their nature should be seen within 24 hr, but which do not need immediate availability of hospital facilities. Emergency/ED - - Problems which, even if not serious, should be seen immediately by a physician; or problems that by their nature are apt to need the facilities which are present only in a hospital.

§Non-urgent - - Does not need medical attention immediately. Urgent - - Patient's condition requires immediate medical attention but life is not in danger. E m e r g e n t - Patient's life is in danger due to illness or injury; medical attention is required immediately.

14/507 Ann Emerg Med 9:10 (October) 1980