Washington Donna L, Stevens Carl D, Shekelle Paul G, Henneman Philip L, Brook Robert H
Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, 111G, Los Angeles, CA 90073, USA.
Ann Intern Med. 2002 Nov 5;137(9):707-14. doi: 10.7326/0003-4819-137-9-200211050-00005.
Because of overcrowding and cost-control efforts, emergency departments are under pressure to refer patients with nonacute conditions to other settings. However, no validated systematic methods exist for safely performing such referrals.
To determine the effects on health status and access to care of systematically referring patients with nonacute conditions to next-day primary care.
Randomized, controlled trial.
An emergency department in a public hospital.
156 adults who used the emergency department on weekdays from 7:00 a.m. to 3:00 p.m. and met criteria for deferred care. The criteria applied to three symptom complexes that account for 33% of U.S. emergency department visits by adults.
Next-day care at the study site's primary care center or usual same-day care.
Self-reported health status and use of health services during 1-week follow-up.
Patients assigned to next-day care did not demonstrate clinically important disadvantages in health status or physician visits compared with usual care patients. In each group, more than 95% of patients were evaluated at least once by a physician, 4% sought health services after their initial evaluation, and no patients were hospitalized or died. At follow-up, both groups reported improved health status and fewer days in bed or with disability, although the deferred care group reported less improvement on all three measures. The 95% CIs were sufficiently narrow to exclude a clinically significant difference in self-reported health status. However, the possibility of 1 additional day in bed or with disability in the deferred care group could not be excluded.
Clinically detailed standardized screening criteria can safely identify patients at public hospital emergency departments for referral to next-day care. However, larger studies are needed to assess the possibility of adverse effects.
由于过度拥挤和成本控制措施，急诊科面临着将非急症患者转诊至其他机构的压力。然而，目前尚无经过验证的系统方法来安全地进行此类转诊。
确定将非急症患者系统地转诊至次日初级保健对健康状况和获得医疗服务的影响。
随机对照试验。
一家公立医院的急诊科。
156名在工作日上午7点至下午3点使用急诊科且符合延迟护理标准的成年人。这些标准适用于占美国成年人急诊科就诊33%的三种症状组合。
在研究地点的初级保健中心接受次日护理或常规当日护理。
1周随访期间的自我报告健康状况和医疗服务使用情况。
与常规护理患者相比，被分配到次日护理的患者在健康状况或看医生次数方面没有表现出临床上重要的劣势。在每组中，超过95%的患者至少接受过一次医生评估，4%的患者在初次评估后寻求医疗服务，没有患者住院或死亡。在随访时，两组均报告健康状况有所改善，卧床或残疾天数减少，尽管延迟护理组在所有三项指标上的改善程度较小。95%置信区间足够窄，可排除自我报告健康状况方面的临床显著差异。然而，不能排除延迟护理组多卧床或残疾1天的可能性。
临床详细的标准化筛查标准可以安全地识别公立医院急诊科适合转诊至次日护理的患者。然而，需要更大规模的研究来评估不良反应的可能性。
