Deciding Who Needs Emergency Care: Triage Guidelines and Gatekeeping

Robert A. Lowe, MD, MPH. LDI Senior Fellow, Senior Scholar, Center for Clinical Epidemiology and Biostatistics, and Assistant Professor of Emergency Medicine, University of Pennsylvania School of Medicine

Volume 2, Number 6; October 1995


Increasing use of the emergency department (ED) has prompted concerns about overcrowding and high costs. In response, providers and payers have instituted triage and "gatekeeping" mechanisms to reduce unnecessary ED use. This Issue Brief summarizes recent research on the safety and effectiveness of some of these mechanisms.

Excess patient volume in urban EDs threatens access to emergency care and quality of care

According to ED directors in public and teaching hospitals, overcrowding in the ED has a negative impact on the quality of, and access to, emergency care. Excess patient volume in the ED leads to:


prolonged waiting times, which can be a significant barrier to obtaining care.
delayed treatment of severely ill patients.
diversion of ambulances to more distant hospitals.

Overcrowding has many causes, but solutions have focused on reducing unnecessary use of the ED

ED utilization has steadily increased for several decades, from 18 million visits in 1958 to more than 99 million in 1992. Overcrowding in the ED may stem from many sources, including:


overburdened inpatient facilities, causing a backup of admitted patients in the ED.
inadequate ED space, staffing, or ancillary services.
an influx of severely ill patients.
an excessive number of patients with minor problems.

The last category, labelled by some as "inappropriate" ED users, has received the most attention from emergency physicians attempting to decrease patient loads and from third-party payers (especially managed care organizations) attempting to contain costs.

Patients, clinicians, payers and policy-makers cannot agree on what constitutes a true emergency.

Some authors suggest that many ED patients can be treated in less acute settings, such as outpatient clinics, by improving access to primary care and by triaging patients out of the ED. Triage assumes that there are agreed-upon criteria for the appropriateness of an ED visit. However, recent research indicates that commonly used measures of appropriateness do not agree with one another, and lead different people to different conclusions.


Patients often decide whether to come to the ED based on self-assessment of the seriousness of their problems.
Triage nurses decide prospectively whether a patient needs immediate care based on triage scores or guidelines.
Physicians decide whether the patient's health would be jeopardized by a 24-hour delay in care based on clinical judgement.
Third-party payers determine retrospectively, for reimbursement purposes, whether the patient's outcome would have been worse without an ED visit.

Triage guidelines for refusing care in the ED should be proven valid and reliable

Strategies to reduce unnecessary ED use run the risk of inadvertently refusing care to patients truly in need of emergency care with resultant medical, ethical, and legal problems. Therefore, guidelines for refusing care should meet the following standards.


Guidelines must be clear and unambiguous so that triage personnel can apply them easily.
They must be tested on patients who are followed after triage to determine whether refusing care might have jeopardized the patients' health.
Their validity must be demonstrated in different settings, with different patient populations.

Published guidelines may not sufficiently identify patients who need emergency care

In a recent study of an ED in an urban public hospital, Robert Lowe and colleagues found that published triage guidelines could not be reliably applied and did not correctly identify patients who needed ED care. Two certified emergency nurses reviewed triage sheets to determine whether patients should have been provided or refused care according to published guidelines.


In the retrospective reviews, the nurse raters disagreed on how to apply the guidelines in 12% of cases.
The triage guidelines had limited ability to predict which ED visits met appropriateness criteria. One-third of the patients who would have been refused care by triage guidelines had ED visits that were appropriate as defined by explicit criteria and an emergency physicianÕs subjective review.

Gatekeeping systems that require telephone authorization from a primary care physician may have negative consequences

Gatekeeping mechanisms, instituted by many managed care plans, require pre-authorization from the primary care physician for an ED visit. In a pilot study of an urban university hospital, 4% of all managed care patients presenting to the ED were denied authorization by the managed care plan. In follow-up phone calls ten days after their attempted ED visit, many patients reported persistence of symptoms and dissatisfaction with their experiences.


One-third of denied patients never saw the primary care physician for their problem.
One-quarter said their problems were the same or worse.
Nearly half expressed dissatisfaction with the gatekeeping process.

Race may be a factor when managed care patients are denied ED care

Preliminary studies have found that African-Americans are more likely to be denied authorization by their primary care physician, even after adjusting for severity of symptoms. The cause of this association is unclear, but raises substantial concerns about the equity with which gatekeeping is practiced.


The findings could represent a difference in severity of illness that was inadequately measured by a triage score.
The race differential could be due to racism on the part of ED providers or primary care physicians.
Alternately, the findings could represent unmeasured racial differences in communication patterns, relationships to doctors, or the quality of doctors.

Policy Implications


The concept "appropriate use of the ED" is much less clear than common wisdom might suggest. Physicians and nurses cannot reliably predict in advance which patients need to be seen in the ED.
Limiting access to EDs without the aid of a valid and reliable definition of appropriate use could result in barriers to needed care and harm to patients' health.
It may be prudent to defer broad application of triage guidelines until they can be validated prospectively, in several EDs, with careful patient follow-up.
Gatekeeping systems should be evaluated for their effect on patient outcomes and for their impact on vulnerable groups, such as racial minorities or the poor.
Further consideration of triage guidelines and gatekeeping strategies should be integrated into a more comprehensive discussion of the role of ED care. This should include assuring patients access to primary care, addressing other causes of ED overcrowding, and determining whether ED care for certain conditions is less effective or more costly that other sources of care.

This brief is based upon the following articles: R.A. Lowe, et al., What is an Appropriate Energency Department Visit? An Explanation for the Failure to Agree (Abstract), Annals of Emergency Medicine (1993;22:240); R.A. Lowe, et al., Refusing Care to Emergency Department Patients: Evaluation of Published Guideline, Annals of Emergency Medicine (1994;23:286-293); S.B. Abbuhl, R.A. Lowe, S.A. Stahmer, S. Chhaya, C. Pierce, What Happens to Managed Care Patients Who Are Denied Care in the ED? (Abstract), Academic Emergency Medicine (1995;2:370-371); R.A. Lowe et al., To Whom Do Managed Care Providers Deny ED Care? (Abstract), Academic Emergency Medicine (1995;2:371).