Non-urgent adult patients in the emergency department

To the Editor:
We read with interest the article by Idil et al. titled “Non-urgent adult patients in the emergency department: Causes and patient characteristics” in the press of 2018 edition of Turkish Journal of Emergency Medicine(1) and we think that non-urgent patients are one of the serious problems of emergency departments (ED) in all the world. Authors aimed to identify the characteristics of these patients and the reasons why they prefer the ED. We congratulate the authors for this valuable study, and we have a few comments.
The main focus of this study is “Non-urgent adult patients in the emergency department”. However, authors did not define the “Non-urgent adult patients” methodologically. It is not clear how “non-urgent” was measured and which objective criteria were used. In studies examining non urgent visits to ED, criteria for ED visits of urgent cases or non-urgent ED visits should be specified in the method section of study fully.(2) The authors stated that “In the triage system used in Turkey, patients are grouped as green, yellow or red, respectively, beginning from the lowest level of urgency to highest.” in the introduction of their article. Green triage code is the lowest level of urgency but not non-urgent patient. In addition, a growing literature inquires about the unnecessary labeling and accusing of patients for inappropriate use of the ED.(2,3) They stated that most common complaints of non-urgent patients were musculoskeletal system pain (25.2%) and upper respiratory tract infections (URTI) symptoms (19.7%). The patients with URTI symptom or musculoskeletal system pain may or may not be a non-urgent patient. According to a systematic review of the emergency medicine literature, criteria such as the patients' vital signs should be considered for identification of the non-urgent patient(2,4). Therefore, choosing only patients who had a green triage code as a non-urgent patient and not specifying the criteria used in the selection of “Non-urgent adult patients” may affect the study outcomes and the reliability and reproducibility of the method.
Patients listed as green triage code may be identified as yellow or red triage code in the ED triage rules soon after4. The authors did not indicate how many patients referred to as green code initially were later yellow or red triage patients. Presentation of these data could be better. There is different triage systems used in the world.(2) Authors stated that the patients were selected based on the convenience sampling method by triage nurses. However, it is not specified which valid triage tool (e.g. Emergency Severity Index) including formal guidelines is used in the ED where this study conducted and a method used for eligible of patients.

References

1. Idil H,etal.Non-urgentadultpatientsintheemergencydepartment:Causesand patient characteristics. Turkish Journal of Emergency Medicine; 2018. https://doi. org/10.1016/j.tjem.2017.10.002.
2. Durand AC, Gentile S, Devictor B, et al. ED patients: how non urgent are they? Systematic review of the emergency medicine literature. Am J Emerg Med. 2011;29(3):333e345. https://doi.org/10.1016/j.ajem.2010.01.003. Epub 2010 Apr 24.
3. Gulacti U, Lok U, Polat H. Emergency department visits of Syrian refugees and the cost of their healthcare. Pathog Glob Health. 2017;111(5):219e224. https:// doi.org/10.1080/20477724.2017.1349061. Epub 2017 Jul 18.
4. Gilboy N, Tanabe P, Travers DA, Rosenau AM, Eitel DR. Emergency Severity Index, Version 4: Implementation Handbook. AHRQ Publication No. 05-0046-2. Rockville, MD: Agency for Healthcare Research and Quality; May 2005.