American Journal of Emergency Medicine (2011) 29, 333–345

www.elsevier.com/locate/ajem

Review

ED patients: how nonurgent are they? Systematic review

of the emergency medicine literature
Anne-Claire Durand MPh a,⁎, Stéphanie Gentile MD, PhD a ,
Bénédicte Devictor PhD a , Sylvie Palazzolo MPh a , Pascal Vignally PhD a ,
Patrick Gerbeaux MD, PhD b , Roland Sambuc MD, PhD a
a
Laboratoire de Santé Publique, Faculté de Médecine, Equipe de recherche EA 3279
“Evaluation hospitalière-Mesure de la santé perçue”13005, Marseille, France
b
Service d'Accueil des Urgences, Hôpital de La Conception 13005, Marseille, France

Received 24 August 2009; revised 29 December 2009; accepted 5 January 2010

Abstract Nonurgent visits to emergency departments (ED) are a controversial issue; they have been
negatively associated with crowding and costs. We have conducted a critical review of the literature
regarding methods for categorizing ED visits into urgent or nonurgent and analyzed the proportions of
nonurgent ED visits. We found 51 methods of categorization. Seventeen categorizations conducted
prospectively in triage areas were based on somatic complaint and/or vital sign collection.
Categorizations conducted retrospectively (n = 34) were based on the diagnosis, the results of tests
obtained during the ED visit, and hospital admission. The proportions of nonurgent ED visits varied
considerably: 4.8% to 90%, with a median of 32 %. Comparisons of methods of categorization in the
same population showed variability in levels of agreement. Our review has highlighted the lack of
reliability and reproducibility
© 2011 Elsevier Inc. All rights reserved.

1. Introduction Other authors consider ED overcrowding to be related to

Nonurgent visits to emergency departments (ED) are a
controversial issue in the emergency medicine literature
[1,2]. Most often, nonurgent ED patients have been
negatively associated with crowding and costs [3-14].
Many authors confuse ED overcrowding and nonurgent
ED visits. For them, an increased proportion of nonurgent
visits would be the main cause of ED overcrowding.
Emergency overcrowding would result in a longer stay in
the ED and would potentially lead to worse outcomes for
persons who truly require emergency care [7,10,14-17].
⁎ Corresponding author. Tel.: +33 4 91 32 44 72; fax: +33 1 91 38 44 82.
E-mail address: anne-claire.durand@ap-hm.fr (A.-C. Durand).
more complex problems: overburdened inpatient facilities,
inadequate ED space, insufficient staffing, an influx of
severely ill patients, or an excessive number of patients with
minor problems [2,8-10,18]. In that line, Schull et al [16]
concluded that the number of nonurgent patients does not
contribute to the longer ED stays.
Because of the confusion between nonurgent ED visits
and ED overcrowding, one of the strategies proposed to
reduce nonurgent visits in ED is to redirect patients identified
as nonurgent to alternative structures for care [9,18,19]. This
strategy is highly debated because it raises ethical and care
safety problems [10,12,20]. The major ethical problem posed
by redirection is the availability, accessibility, and afford-
ability of another source of care, especially for vulnerable
populations [7,21]. Another problem posed by redirection is

0735-6757/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajem.2010.01.003
334
that of safety of care, with the risk of inadvertently refusing
care to patients truly in need of emergency interventions
[10,12,20].
Controversy about the additional costs that would result
from nonurgent ED visits also exists [7,8,12,13,22-24].
Richardson and Hwang [1] and Williams [13] have shown
that the true cost of nonurgent care in ED is much lower than
is widely believed because of the high fixed costs of operat-
ing ED and the relatively low marginal costs. The average
cost would therefore decrease as the number of patients
increases. Hence, redirecting nonurgent visits to alternative
sources of care may not be highly cost-effective [13].
Because the problem of nonurgent ED visits is quite
complex, we have conducted a critical review of the literature
to answer the following questions:
- How have authors measured nonurgent ED visits?
- What is the proportion of nonurgent ED visits in
published articles?
- Does the proportion of nonurgent ED visits vary
according to the measurement criteria?
2. Materials and methods
A structured literature search was conducted via PubMed,
National Library of Medicine. We included all articles
focusing on nonurgent visits of adult patients presenting to
the ED that were published in English from 1980 to 2008.
The literature search involved a combination of key words
with free text and Medical Subject Headings (MeSH) terms.
The final keyword search was with ((“nonurgent” OR “non-
urgent” OR “nonemergency” OR “minor illness” OR “minor
problem” OR “inappropriate” OR “misuse” OR “could have
been treated by general practitioner”) AND (“Emergency
Service, Hospital/utilization” [Mesh] OR “Emergency Med-
ical Services/utilization” [Mesh] OR “emergency department
use” OR “emergency department visit”)) OR (“Triage/
methods” [Mesh]).
The findings by PubMed search were screened by titles
initially relevant for defining patients as nonurgent or use as
inappropriate. Articles whose titles were not clearly relevant
were reviewed at the abstract level. Finally, we reviewed the
references in each of the retained articles to look for any other
articles that might have been missed in the initial research.
For each article included, we analyzed the following
end points:
- the time of triage when ED visits were categorized into
urgent or nonurgent cases. Two times of triage were
identified:
- prospectively in the triage area and
- retrospectively, at the end of the consultation or
based on review of medical records or analysis of a
national database.
A.-C. Durand et al.
- the profile of the health professional who conducted the
categorization visits;
- criteria used to categorize nonurgent visits. We
classified the criteria into 2 categories: explicit, that
is, measurable and reproducible, like vital signs and
diagnostic tests performed in the ED, and implicit, that
is, based on expert or patient opinions;
- the proportion of nonurgent ED visits found in
articles; and
- the definition of nonurgent ED visits given by the
authors.
The results are presented according to the different methods
of categorizing ED visits because few authors have compared
several methods of categorization for the same population. In
“Results,” we use the term “methods of categorization.”
3. Results
The search via PubMed produced a total of 658 potential
articles. We selected 75 articles on the basis of the relevance
of the title. After reading their abstracts, we selected 27
articles that reported the proportion of nonurgent ED visits
and the assessment method used to categorize visits
[2,11,19,21,24-46]. We included 12 additional articles
based on the analysis of the references [9,10,18,47-55].
Among these, 6 articles compared several methods for
categorizing ED visits [28,31,36,39,43,51], totaling 51
methods of categorization. Table 1 presents the 39 articles
selected with the different relevant end points describing
methods of categorization.
3.1. Methods to categorize ED visits into nonurgent
or urgent cases
Among the 51 methods of categorization found, we
conducted an analysis of 3 common end points: the time of
triage, the profile of the health professional who conducted
the categorization, and the criteria used to categorize ED visits.
Among the 51 methods of categorization, 17 were
conducted prospectively in the triage area (33.3%)
[9-11,18,19,26-28,31,32,36,39,43,48,49,51,55] and 34
(66.7%) retrospectively: 15 at the end of the consultation
[2,10,28,30,32,33,35,36,39,44-47] and 19 retrospectively
based on the medical records [21,24,25,29,34,37,38,40-
43,50,52-54]. The categorization was performed by 2 sorts
of health professionals: a triage nurse or a physician.
Among the 17 categorizations performed in the triage area,
15 were done by triage nurses (88.2%) [9-11,18,19,26-
28,32,39,43,48,51,55] and 2 by ED physicians (11.8%)
[28,49]. The 34 categorizations performed after the exam-
inations were all done by ED physicians.
Among the 51 methods of categorizations, 36 used only
explicit criteria [2,9-11,18,19,21,24-26,28-31,34-38,41-
Nonurgent patients in emergency department 335

Table 1 Methods to categorize ED visits into urgent and nonurgent cases and proportions of nonurgent ED visits
Reference Time of triage Health Criteria for categorizing ED visits Definition of NU ED visits NU ED
professional into urgent cases a visits (%)
Afilalo et al Retrospectively ED Explicit criteria: referred to the ED by Inappropriate users: 15.2
[25] based on the physicians other medical source; complaints and “persons who could have
medical records their duration; time of the visit; waited to be assessed in the
review potential emergency in diagnosis; ED or other outpatient
investigations performed in the ED; facility more than 6 h from
treatment performed in the ED; the time of initial
observation or reassessment in the ED; presentation”
hospital admission
Afilalo et al Prospectively Triage nurses Use of the CTAS based on explicit NU patients: “persons who 25
[26] in triage area criteria: list of presenting complaints; could have waited 2
determination of pain severity; vital h before being seen by a
signs physician”
Bianco et al Prospectively Triage nurses Explicit criteria derived from NU cases: “no active 19.6
[27] in triage area emergency medicine literature symptoms or they were
[14,40,48]: list of 32 most common recent and minor, without
chief complaints; duration of any feeling of emergency”
symptoms; investigations performed in
the ED; vital signs
Implicit criteria: impression of the
potential for rapid deterioration in the
patient's condition; urgency perceived
by patients
Brillman et al (1) and (2) (1) Triage (1) Explicit criteria based on a list of Definition unspecified. (1) 37.4
[28] Prospectively nurses 80 common emergency complaints
in triage area
(2) Software (2) Use of “AMOS classifications” (2) 39
software based on explicit criteria
covering 80 common emergency
complaints
(3) Retrospectively (3) ED (3) Explicit criteria: list of 80 common (3) 32.1
at the end of the physicians emergency chief complaints; reviewed
consultation in the nursing notes; vital signs; hospital
1 or 2 min admission
Buesching Retrospectively ED Use of the ACEP guidelines based on Inappropriate visits: 10.8
et al [29] based on the physicians explicit criteria: hospital admission; “symptoms present for more
medical records paramedic run; vital signs; medical than 72 hours without
review complaints and their duration; referred change and for which the
by a physician; hours or days of arrival; patient did not attempt to
unsuccessfully attempted to contact contact a personal physician”
a physician
Carret et al Retrospectively ED Use of the HUAP based on explicit Definition unspecified. 24.2
[30] at the end of the physicians criteria: vital signs; list of medical
consultation complaints; duration of symptoms;
treatment performed in the ED;
investigations performed in the ED;
observation or hospital admission;
specific circumstances for self-referred
patients (accident; symptoms
suggesting vital emergency; a
known condition that usually leads
to hospitalization; the patient's
physician advised that he/she needed
to go to the ED if symptoms appear;
the hospital was the closest center)
(continued on next page)
336 A.-C. Durand et al.

Table 1 (continued)
Reference Time of triage Health Criteria for categorizing ED visits Definition of NU ED visits NU ED
professional into urgent cases a visits (%)
Caterino et al (1) Prospectively (1) Patients (1) Implicit criteria: patient's self- NU patients: “care could (1) 28
[31] in triage area assessment safely wait up to 24 hours”
(2) and (3) (2) ED (2) Explicit criteria based on the initial (2) 31
Retrospectively physicians clinical examination without diagnostic
at the end of the tests
consultation (3) ED (3) Explicit criteria: diagnostic tests (3) 40
physicians performed in the ED
Dale et al [32] Prospectively Triage nurses Explicit criteria: mode of referral; Primary care attendees: 40.9
in triage area symptoms and medical complaints “self-referred with
Implicit criteria: potential hospital symptoms likely caused by
admission conditions not in need of
immediate resuscitation or
urgent care, unlikely to
require hospital admission,
and self-referred patients
with NU complications of
chronic conditions”
David et al Retrospectively ED Use of an index of appropriateness of Definition unspecified. 49.9
[33] at the end of the physicians ED based on 7 criteria
consultation Explicit criteria: arrived by paramedic
vehicle or ambulance; investigations
performed in the ED; hospital
admission; referred to the ED by other
medical source
Implicit criteria: severe sensations of pain
or discomfort reported by the patient;
self-assessed emergency level; suspicion
of an acute, life-threatening illness or
condition reported by the patient
Davison et al Retrospectively ED Explicit criteria: medical complaints; Definition unspecified. 39
[34] based on the physicians required surgical emergency
medical records
review
De Vos et al Retrospectively ED Use of the guideline and scale used in Definition unspecified. 57.9
[35] at the end of the physicians the Cuban health system based on
consultation explicit criteria: medical complaints;
vital signs; investigations performed in
the ED; treatment performed in the ED;
observation
Derlet et al Prospectively in Triage nurses Explicit criteria: list of 50 minor Definition unspecified. 1990: 19
[9,18,19], 3 triage area complaints; vital signs; a brief history 1992: 15.4
articles of the chief complaints; an examination 1995: 18
focusing on the area of the chief
complaint
Driscoll et al Retrospectively at ED Implicit criteria: expert opinion; Inappropriate cases: “who 40
[47] the end of the physicians patient's self-assessment could clearly have been
consultation Explicit criteria: GP registration; prior seen by a GP or who
contact GP; duration of the problem required no medical
attention at all”
Frey et al [36] (1) Prospectively (1) Patients (1) Implicit criteria: patient's Same definition as (1) 10%
in triage area self-assessment Buesching et al [29]
(2) and (3) (2) ED (2) Implicit criteria: perception of the (2) 24.4
Retrospectively at physicians appropriateness of the visit; perception
the end of the of the urgency of the visit; perception
consultation of how soon the care was needed
Nonurgent patients in emergency department 337

Table 1 (continued)
Reference Time of triage Health Criteria for categorizing ED visits Definition of NU ED visits NU ED
professional into urgent cases a visits (%)
(3) ED (3) Use of the ACEP guidelines and use (3) 31.7%
physicians of a modification of a previous study by
Schull et al [16] based on explicit
criteria: complaints and their duration;
chest pain as the chief symptom; vital
signs; hospital admission; arrived by
ambulance; referred to the ED by other
medical source
Grumbach Prospectively in Triage nurses Use of written guidelines with acuity Definition unspecified. 34.2
et al [48] triage area scores based on explicit criteria: vital
signs; complaint and their duration
Haddy et al Retrospectively ED Explicit criteria: list of complaints Definition unspecified. 82
[37] based on the physicians
medical records
review
Hansagi et al Retrospectively ED Explicit criteria developed by NU problem: “persons who 38.3
[38] based on the physicians McMillan et al [56]: complaints and could have been treated by
medical records their duration; required emergency their GP or for whom
review treatment in the ED treatment time was not
particularly important or
urgent from a medical
perspective”
Kelly et al (1) and (2) Implicit criteria NU problem “could have
[39] Prospectively in (1) Patient (1) Patient's self-assessment been deferred 12 to 24 (1) 27
triage area (2) Triage (2) Expert opinion hours to be seen by a GP” (2) 49
nurses
(3) Retrospectively (3) ED (3) Expert opinion (3) 49
at the end of the physicians
consultation
Krakau and Prospectively in ED Explicit criteria: preliminary diagnosis NU patients “did not need 27.5 b
Hassler triage area physicians Implicit criteria: required potential the equipment or special
[49] investigations in the ED skills of a hospital ED and
could have been treated
with or without delay at a
primary health care center”
Lang et al Retrospectively ED Explicit criteria: symptoms and their NU visit: “if the symptom 31.7 b
[40] based on the physicians duration; investigations performed were not recent, or recent
medical records in the ED and minor”
review (study in Nurses Implicit criteria: urgency perceived
2 hospitals) by patients
Lee et al [50] Retrospectively ED Explicit criteria based on the GP case: “could be 57
based on the physicians International Classification of Primary managed by GPs”
medical records Care: symptoms and complaints;
review investigations performed in the ED;
treatment performed in the ED; diagnosis
Liu et al [24] Retrospectively ED Explicit criteria: complaints; NU visit: “does not require 53.72 b
based on the physicians investigations performed in the ED; attention immediately or
medical records treatment performed in the ED within a few hours”
review for
5 periods
(1992-1996)
(continued on next page)
338 A.-C. Durand et al.

Table 1 (continued)
Reference Time of triage Health Criteria for categorizing ED visits Definition of NU ED visits NU ED
professional into urgent cases a visits (%)
Lowe et al (1) Prospectively (1) Triage (1) Explicit criteria adapted from the Definition unspecified. (1) 21.7
[10] in triage area nurses triage guideline for “refusal of ED
care” developed by Derlet et al
[9,18,19]: list of 50 minor complaints;
vital signs; previous medical history;
an examination focusing on the area of
the chief complaint
(2) Retrospectively (2) ED (2) List of 10 explicit criteria to Definition unspecified. (2) 35.3
at the end of the physicians determine whether resources were
consultation used: hospital admission;
investigations performed in the ED;
treatment performed in the ED
Lowe and (1) and (2) Implicit criteria Definition unspecified.
Bindman Patients (1) Willing to trade ED visit for a (1) 37
[51] clinic appointment
(2) Self-assessment of acuteness (2) 10
(3) and (4) (3) and (4) (3) Implicit criteria based on a four- (3) 31
Prospectively in Triage nurses point acuity scale
triage area (4) Explicit criteria adapted from the
triage guideline for “refusal of ED (4) 22
care” developed by Derlet et al
[9,18,19]
(5) to (7) ED (5) Explicit criteria: hospital (5) 90
Retrospectively physicians admission
based on the (6) Explicit criteria: investigations
medical records performed in the ED; treatment
review performed in the ED; hospital
admission (6) 34
(7) Implicit and explicit criteria: (7) 20
“Would be seen 24 hours later without
worse outcomes?” “If not,” according
to history, physical or ancillary data,
treatable 24 h later without worse
outcomes
Lowy et al Retrospectively Panel of GPs Explicit criteria based on Definition unspecified. 23.4
[41] based on the (1) The Nuffield Provincial Hospitals
medical records Trust diagnostic classification of
review clinical needs
(2) The ICD-9
(3) The Sheffield Process Definition:
registered with a GP; not investigated
in ED; not treated in ED except for a
prescription, bandage, sling, dressing
or steri-strips; did not come from a
motor vehicle accident or an accident at
work, school, a public place or a
sporting event; discharged completely
from care in ED or referred to their GP
Martin et al Retrospectively Panel of GPs Explicit criteria according to a Inappropriate cases if at 16.8
[42] based on the and nurses modified SPM to identify cases of least 4/5 agreement:
medical records “inappropriate” ED attendance (see “criteria not met and
review criteria set by Lowy et al [41]): if attendance more than 48
criteria of the SPM not met, the panel hours after the onset of the
assessed the duration of the problem illness or injury and all
and results of all investigations investigations are normal”
Nonurgent patients in emergency department 339

Table 1 (continued)
Reference Time of triage Health Criteria for categorizing ED visits Definition of NU ED visits NU ED
professional into urgent cases a visits (%)
McCaig and Retrospectively ED Explicit criteria: clinical diagnosis Nonurgent visit: delay of 12.5
Nawar [52] based on the physicians based on the ICD-9 “2-24 hours”
analysis of a
national database
Mitchell and Retrospectively ED Explicit criteria: clinical diagnosis Definition unspecified. 4.8
Remmel based on the physicians based on the ICD-9
[53] analysis of a Implicit criteria: expert opinion
national database
Nourjah [54] Retrospectively ED Explicit criteria: complaint and clinical NU visit: “between 2 and 24 9.7
based on the physicians conditions hours. A delay of up to 24
analysis of a Implicit criteria: expert opinion hours would make no
national database appreciable difference.”
O'Brien et al (1) Prospectively (1) Triage (1) Explicit criteria based on a list of Definition unspecified. (1) 58
[43] in triage area nurses 51 NU complaints derived from the
literature [9,57]
(2) and (3) (2) ED (2) A list of 10 explicit criteria to (2) 42
Retrospectively physicians determine whether resources were used
based on the [10]: hospital admission; investigations
medical records performed in the ED; treatment
review performed in the ED
(3) ED (3) Implicit criteria based on expert (3) 47
physicians opinions: “could the patient be treated
by a GP within 24 hours without
harm?”
Oktay et al Retrospectively at ED Explicit criteria developed by Afilalo NU patient: “could have 31.2
[44] the end of the physicians [25]: referred to the ED by other waited to be assessed in the
consultation medical source; investigations ED or other outpatient
performed in the ED; treatment facility more than 6 hours
performed in the ED; observation and from the time of initial
reassessment in the ED; complaints and presentation”
their duration; time of the visit to the
ED; availability of an outpatient facility
Pereira et al Retrospectively at ED Explicit criteria based on a list derived Definition unspecified. 31.3
[45] the end of the physicians from emergency medicine literature
consultation [10]: transfer from other medical
source; hospital admission; death
occurred in the ED; investigations
performed in the ED; treatment
performed in the ED
Petersen et al Retrospectively ED Explicit criteria based upon triage Definition unspecified. 50
[21] based on the physicians criteria developed by Baker et al [14]:
medical records list of criteria taking into account the
review vital signs, duration of the complaint,
age, sex, comorbidities, and results of
diagnostic tests
Rubin and Prospectively in Triage nurses Explicit criteria based on list of 42 Definition unspecified. 37.1
Bonnin triage area criteria: referred to the ED by any
[55] health care facility; list of 18 medical
complaints; vital signs
Implicit criteria: potential hospital
admission
Sempere- Retrospectively at ED Use of the HUAP list of explicit criteria Definition unspecified. 29.6
Selva et al the end of the physicians (see criteria set by Carret et al [30])
[2] consultation
(continued on next page)
340
Table 1 (continued)
Reference Time of triage Health
professional
Shah et al Retrospectively at ED
[46] the end of the physicians
consultation
Young et al Prospectively in Triage nurses
[11] triage area
NU indicates nonurgent; GP, general practitioner; CTAS, Canadian Triage and Acuity Scale; AMOS, Automated Military Outpatient System; ACEP,
American College of Emergency Physicians; HUAP, Hospital Urgency Appropriateness Protocol; SPM, Sheffield Process Method; ICD-9, International
Statistical Classification of Diseases and Related Health Problems.
a
Except Derlet et al [9,18,19] and articles referring to Derlet et al [10,43,51] for classifying “refusal of ED care,” Lowy et al [41] and Martin et al [42].
b
Means.
46,48,50-52], 5 only implicit criteria [36,39,43,51], and 10 a
combination of both [27,32,33,40,47,49,51,53-55]. Table 2
presents the criteria used to categorize ED visits. The explicit
criteria most commonly used were focused on the chief
complaint (in 31 categorizations), the duration of the
complaint (9 categorizations), vital signs (17 categoriza-
tions), the type of referral (11 categorizations), diagnostic
tests (19 categorizations), treatment performed in the ED
(16 categorizations), and hospitalization (15 categorizations).
Table 3 presents the criteria used to classify ED visits
according to the time of triage. Most categorizations
conducted prospectively (n = 17) were based on criteria
related to a somatic complaint by the patient (14/17)
[9-11,18,19,26-28,32,43,48,51,55] or vital sign collection
(10/17) [9-11,18,19,26,27,48,51,55]. A combination of these
2 criteria was found in 10 of these 17 methods of
categorization [9-11,18,19,26,27,48,51,55]. Only 2 methods
included, in addition, the type of patient arrival (self-referred
or not) [32,55] and 5 included an additional criterion, which
is a basic initial clinical examination performed by nurses
in the triage area [9,11,18,19,51].
Categorizations conducted retrospectively (n = 34) were
based on a combination of the 3 following criteria: the
diagnosis, the results of laboratory/imaging tests during the
visit, and the decision to admit the patient to the hospital.
3.2. Variability in the proportions of nonurgent
ED visits
Our literature review showed considerable variability in
the proportions of nonurgent ED visits, ranging from 4.8%
[53] to 90% [51], with a median overall of 32.1%. Table 4
shows the variability of the proportions of nonurgent ED
visits according to the time of triage and categories of
criteria. The proportion of nonurgent ED visits was the
lowest when categorization was performed prospectively in
the triage area and based on explicit criteria. The proportion
A.-C. Durand et al.
Criteria for categorizing ED visits Definition of NU ED visits NU ED
into urgent cases a visits (%)
Explicit criteria: type of referral; final Definition unspecified. 61
diagnosis; type of follow-up needed;
hospital admission
Explicit criteria: chief complaints; brief NU visit: “problem or 49
history of the complaint; vital signs; condition that could wait
brief examination performed to until the next day (i.e., 12 to
determine the urgency of the patient 24 hours)”
condition
of nonurgent ED visits was the highest when the categori-
zation was retrospective and based only on implicit criteria.
Five of the methods of categorization showed extreme
values; all were obtained with retrospective categorization
[37,46,51,53,54]. Among these extreme values, the 2 lowest
(4.8% [53] and 9.7% [54]) were found on the analysis of
diagnosis from a national database. Among the 3 highest, 2
(61% [46] and 90% [51]) were obtained only on the criterion
of hospital admission, that is, all patients not hospitalized were
considered as nonurgent cases [46,51], and one (82% [37])
was obtained from a list of complaints, including minor
lacerations and minor contusions [37], which are not
considered insults that can be treated by a general practitioner.
If the proportion is recalculated by excluding these com-
plaints, the proportion of nonurgent ED visits is lower (59%).
3.3. Definition of a nonurgent ED Visit
This review found no specific universal definition of
nonurgent ED visits. Among the 2 definitions found, the
most frequent was based on the concept of “delay of care”
(11 articles): the delay of care ranged between 3 and 72 hours
[11,24-26,31,32,39,44,49,52,54]. Five articles were based on
the duration of symptoms before ED consultation
[27,29,36,40,42]; for example, Buesching et al [29] define
as nonurgent a patient who presented in ED more than 72
hours after an injury.
3.4. Cases between different methods
Six articles compared different methods of categorization
in the same population [28,31,36,39,43,51]. These articles
showed considerable variability in levels of agreement
between the different methods to categorize ED visits into
nonurgent or urgent cases (Table 5), ranging in κ value from
−0.04 [51] to 0.74 [39]. The lowest κ values were when the
views of patients were compared with the opinions of
Nonurgent patients in emergency department 341

Table 2 Criteria used to categorize ED visits into nonurgent this variability are the time of triage and the variability of
cases and frequency of citing criteria among 51 methods of criteria used for categorization. Indeed, there are 2 times of
categorization triage, prospectively in the triage area and retrospectively at
Types of criteria Criteria used to Frequency the end of the consultation. These 2 times of triage serve
categorize ED visits of citing different purposes.
into nonurgent cases criteria Categorization conducted prospectively in the triage area
Explicit criteria is generally performed by triage nurses using formal
Before arrival at the ED guidelines. This categorization has 2 goals: the first is to
Type of referral to Self-referred 11 optimize the length of stay; in this case, one seeks to identify
the ED urgent patients to be treated in the most expeditious way in
Time of arrival During office hours 3 ED. The second goal is to redirect nonurgent patients outside
(hours/days) the ED to primary care structures; this approach raises legal,
Usual source of care Registered by general 3 ethical, and care safety problems. For example, in France
practitioner
About the presenting
complaint Table 3 Criteria used to categorize ED visits into urgent and
Presenting complaint Minor complaint 31 nonurgent cases according to the time of triage
Comorbidities Comorbidities not 1 Time of triage
presented
Duration of the Duration varies 9 Prospectively Retrospectively Total
complaint between 24 and 48 h Methods of 17 34 51
History of the Problem without 8 categorization
complaint evidence of Explicit criteria quoted 15 31 46
deterioration Based on the
Vital signs Normal vital signs 17 circumstances of the
About consultation arrival at the ED
in the ED Type of referral to 2 9 11
Initial examination Normal examination 5 the ED
in triage Time of arrival – 3 3
Examination performed Normal examination 2 (hours/days)
by the ED physician Usual source of care – 3 3
during the consultation Based on the
Diagnostic tests Not investigated in the 17 presenting complaint
performed in the ED ED/normal diagnostic Presenting complaint 14 17 31
tests Comorbidities – 1 1
Treatment performed in Not treated in the ED 15 Duration of the 1 8 9
the ED complaint
Diagnosis Asymptomatic 7 History of the 6 2 8
problem/minor complaint
diagnosis Vital signs 10 7 17
Hospitalization Not hospitalized 13 About consultation
Implicit criteria in the ED
Patient's Without any feeling 4 Initial examination 5 – 5
self-categorization of emergency in triage
Based on expert opinion Deemed inappropriate 13 Examination – 2 2
performed by the ED
physician during
professionals [51] and when patients were categorized solely the consultation
on the criterion of hospitalization [51]. The highest rate of Diagnostic tests – 17 17
performed in the ED
agreement (κ = 0.74) [39] was based on categorization using
Treatment performed – 15 15
solely expert opinion (implicit criteria). in the ED
Diagnosis – 7 7
Hospitalization – 13 13
4. Discussion Implicit criteria quoted 6 9 15
Patient's 1 3 4
self-categorization
This literature review shows considerable variability in Based on expert 6 7 13
the proportions of nonurgent ED visits, with values ranging opinion
from 4.8% to 90% [2,9-11,18,19,21,24-55]. The reasons for
342 A.-C. Durand et al.

Table 4 Proportion of nonurgent ED visits depending on pay is a dangerous approach. For example, Derlet et al [19]
categories of criteria and time of triage studied the feasibility of categorizing patients as nonurgent
Categories of criteria used Time of triage and redirecting them away from ED. This study showed that
2% of patients categorized as nonurgent in the triage area
Prospectively Retrospectively
return to the ED complaining of their inability to gain access
(n = 17) (n = 34)
to care elsewhere. Moreover, a review of the triage nurses'
Explicit criteria only medical records revealed that 0.4% of patients categorized as
Methods of categorization (n) 11 25 nonurgent and redirected actually presented high-risk
Median 25.0% 34.0% conditions. Similarly, Birnbaum et al [20] and Lowe et al
Minimum 15.4% 10.8%
[10] used the criteria of Derlet et al and found that
Maximum 58.0% 90.0%
25th percentile 19.0% 26.9% hospitalization rates of 1.1% and 3.8%, respectively,
75th percentile 39.0% 51.8% among patients triaged away from the ED.
Implicit criteria only Categorization conducted retrospectively at the end of the
Methods of categorization (n) 2 3 consultation is necessarily biased in its approach. Indeed, this
Median 40.0% 47.0% categorization cannot be used to redirect nonurgent patients
Minimum 31.0% 24.4% and therefore cannot be aimed at reducing ED visits. The sole
Maximum 49.0% 49.0% purpose of such categorization is to provide information on
25th percentile 31.0% 24.4% the problem of nonurgent ED patients. It provides an
75th percentile 49.0% 49.0% estimate of nonurgent consultations and serves to analyze the
Explicit and implicit criteria profile of these patients.
Methods of categorization (n) 4 6
Our literature review also shows a lack of consensus on
Median 32.3% 25.8%
Minimum 19.6% 4.8% categorization criteria, whose choice depends on the time
Maximum 40.9% 49.9% of triage. The criteria based on diagnostic investigation,
25th percentile 21.6% 8.5% treatment, diagnosis, and outcomes of the consultation are
75th percentile 39.9% 42.5% necessarily limited to retrospective categorizations. How-
ever, consensus is lacking even on the criteria most often
found in articles, that is, complaints and vital signs,
whatever the time of triage. For complaints, some articles
according to a law enacted in 2003 [58] and in the United provide a detailed list of complaints or situations with the
States, according to the Emergency Medical Treatment and goal of quickly categorizing the consultation as urgent or
Active Labor Act [59], it is never permissible to discharge or nonurgent. Other articles mention only examples of
refer a patient on the basis of triage alone Indeed, any patient complaints. For the vital signs (temperature, blood
who comes to the ED requesting “examination or treatment pressure, pulse, and respiratory rate), the predetermined
for a medical condition” must be provided with “an ranges differ from one study to another, and in some cases,
appropriate medical screening examination” to determine if the authors interpret these predetermined ranges according
she or he is suffering from an “emergency medical to age.
condition” [58,59]. Several authors have discussed ethical Moreover, the lack of consensus on methods of
and safety problems related to reorientation [10,12,20]. categorization and criteria prevents redirecting nonurgent
Indeed, redirecting a patient who seeks care for a medical patients to other health care facilities because of the risk of
problem in the ED without ascertaining the availability of misclassifying these patients, as shown by the 6 articles
alternative sources of medical care and the patient's ability to comparing methods of categorization [28,31,36,39,43,51].

Table 5 Agreement between different methods to categorize ED visits into urgent and nonurgent cases (κ values)
Opinion of Patient's Guidelines or explicit Criterion of hospital
ED physicians self-categorization criteria admission
Opinion of triage nurses 0.20 [51] −0.04 [51] 0.27 [51] 0.07 [51]
0.74 [39] 0.5 [39]
Scale of triage used by triage nurses 0.01 [51] −0.05 [51] 0.39 [43] 0.07 [51]
0.42 [43] 0.56 [28]
Opinion of ED Physicians 0.58 [39] 0.01 [51] 0.02 [51]
−0.01 [51] 0.42 [43]
21.5% [31] a 0.61 [36]
Patient's self-categorization −0.03 [51] −0.03 [51]
a
Percentage of agreement.
Nonurgent patients in emergency department
The lack of consensus is related to confusion between the
concepts of nonurgent and of inappropriate ED visits. The
terms used to define ED misuse also differ widely. Various
authors make no distinction between the terms “inappropriate”
and “nonurgent” for describing ED misuse. The term
“nonurgent” indicates mainly the level of severity of the
medical problem that results in an ED visit (such as vital signs,
being hospitalized or not…). In contrast, the term “inappro-
priate” covers, in addition to the medical problem, the social
and psychological contexts of patients, visiting hours (during
business hours or not), and availability of health care around
the ED. Criteria based on the circumstances of the ED visit are
rarely presented in articles using the term “inappropriate.”
In addition, the concept of “non-urgency” is often defined
in opposition to the concept of “vital urgency”; that is, a
problem that is not likely life-threatening does not require
immediate attention and is considered as nonurgent because
the care can be delayed for several hours or days. This view
is very restrictive and could lead to classifying traumatic
pathologies as “nonurgent” or “inappropriate.” Another
example is persons who seek care to relieve symptoms of
pain or discomfort and who may not want to wait several
days to be treated even if this delay is not medically
significant. The concept of delay of care then is not relevant.
Sometimes, the concept of “non-urgency” is opposed to
the criterion of “hospitalization.” The criterion for hospital-
ization is not fully relevant because it may reflect a serious
medical problem but also an associated social problem.
Some studies have conducted categorizations on the same
patients prospectively in the triage area and retrospectively at
the end of the consultation and showed that hospitalized
patients were identified in the triage area as nonurgent [11].
Altogether, if one analyzes the profitability of ED, the
proportion of patients with life-threatening symptoms is very
low, 15% to 20% [5,60]. Reducing the activity of ED only to
those urgent consultations would be inefficient and could
lead to closing these ED.
Besides the lack of consensus on methods of categoriza-
tion and criteria, a selection bias seems to occur due to the
number of patients excluded from reviewed studies. The
authors have systematically excluded patients requiring
immediate treatment and those with communication diffi-
culties (language barriers, altered mental status). There are
often additional exclusion criteria specific to each study that
further underline the selection bias. If the proportion of
nonurgent ED visits were calculated on the total population,
it would be lower. The quantification of selection bias was
difficult to estimate because the authors do not always
provide the proportion of patients excluded.
5. Limitations
First, we limited our research to English-language articles.
Nevertheless, the selected articles have reported on surveys
343
in 15 countries, providing a large representation of the
problem of nonurgent ED visits. Second, we excluded only
articles on emergency pediatric consultations. However,
some articles included did not distinguish children from
adults. Third, we conducted research on only one database,
PubMed. Our research terms may not have revealed all
aspects of the topic. However, the references of each relevant
article were analyzed to ensure that our review was
exhaustive. Finally, we did not conduct a formal meta-
analysis because of the variability of data considered in each
article and the breadth of study designs.
6. Conclusions
This literature review showed considerable variability
concerning methods and criteria for categorizing ED visits
nonurgent, which induced a wide range in the proportions
of nonurgent ED visits (4.8%-90.0%). Moreover, this
review has highlighted the lack of reliability and reproduc-
ibility of these methods, as evidenced by the low levels of
agreement. Nonurgent patients remain a poorly identified
population, reflecting a complex issue. Indeed, many
elements enter into the decision process for categorizing
nonurgent patients, such as medical, social, and environ-
mental factors. This explains the difficulty in developing
guidelines and ensuring replicability of implementation. We
recommend that because of the large risk of error, none of
these methods should be used to redirect nonurgent patients
outside the ED.
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