Failure to validate a predictive model for refusal of care to emergency-department patients

To determine whether previously developed triage criteria for refusal of care to patients presenting to an emergency department (ED) with nonurgent problems could be validated for an independent patient population.

A convenience sample of 534 adults presenting to a municipal hospital ED between July 1, 1992, and October 15, 1992, who met preestablished criteria for refusal of care were entered into a prospective, observational, cohort study. The single target outcome variable was hospitalization. In order to optimize the criteria's performance, both the triage nurse and the physician caring for the patient had to agree that all criteria for "refusal of care" were specifically met. No patient was refused care, nor was a patient's management or disposition interfered with in any way by the investigators. All patients were followed until hospital admission or release from the ED.

Six (1.1%) of 534 patients (95% CI 0.4-2.4) who met the criteria for refusal of care were hospitalized. This represents a greater than 50-fold difference in incidence of hospitalization when compared with that found by other investigators, who reported that only 0.02% (95% CI 0.0004-0.04) of those patients who were refused care subsequently required hospitalization (p < 10 (-7)).

The authors were unable to validate a previously developed predictive model for refusal of care to patients presenting to an ED. Refusal of care to selected ED patients based on current guidelines is not a viable solution to overcrowding. Alternative strategies must be sought.