Refusing care to patients who present to an emergency department.

In July 1988, our emergency department adopted a policy of refusing to treat patients in the ED if they failed to have what was considered an emergency condition. Screening examinations were performed by triage nurses to determine whether patients were eligible to be seen in the ED. Patients whose vital signs fell within specific categories and who had one of 50 minor chief complaints were refused care in the ED and referred to off-site clinics. The referral of these patients out of the ED after a screening examination falls within the scope of legislation governing ED care and transfer (federal COBRA, Cal SB-12, and Title 22) as determined by the University of California legal counsel. In the first six months of this new triage system, 4,186 patients were referred from the ED; this represented 19% of total ambulatory patients who presented to the triage area. Of the 4,186 patients refused care, 84% were referred to off-site nonuniversity clinics, and 15% were referred to a university-affiliated faculty-staffed clinic. Follow-up letters and telephone calls to their clinics identified no patients who needed retriage to an ED, and only 54 patients (1.3%) complained about their referral out of the ED. Only 42 patients returned to the ED within 48 hours of initial triage, and none had a deterioration of their condition. In conclusion, a selective triage system may be used to effectively decompress an ED, although further study is needed to identify potential rare adverse outcomes.