Thus, prudent layperson statutes contribute substantially to determining who comes to an ED, and EMTALA mandates that they all be seen.

An important illustration of the quandary shared by insurers and emergency physicians is provided by a study of the incidence of application of evidence-based treatment of patients in a specialized Pediatric Emergency Department (PED). In this study, while evidence-based treatment decisions were made in a reassuringly high percentage of cases, more than one-third of all cases presenting to the PED required no therapeutic intervention. The decision not to treat was, of course, itself also evidence-based and could only be arrived at through thorough clinical assessment and appropriate application of evidence-based rules. Which, if any, of the one-third of all cases that did not require treatment might, by some lights, be defined as “unnecessary,” and how could this be if the clinical encounter itself were “necessary” to make this determination?

Thus, prospective definition and determination of “unnecessary” ED visits tends to prove illusory for insurers, and for emergency physicians is rendered moot by the provisions of EMTALA. Retrospective determinations of “unnecessary” are fraught with complexity and potential for error at best, and, at least from a patient perspective, at worst are outright fictions.

In response to the communication from Capital BC to PaACEP (email from Leona Wickenheiser to PaACEP Executive Director David Blunk, March 26, 2013) we will endeavor to provide answers to the questions posed to the chapter.

Questions

1. Knowing that once a patient enters the ED seeking care the patient cannot be turned away:

• What percentage of ED cases seen are considered emergencies?
• What percentage of cases should have gone to urgent care centers?
• What percentage could have waited to see the PCP?

PaACEP has no internal statistical database to draw on to answer these questions with any real-world validity.

Certainly, based on Capital BC references to the highest volume ED visits, most cases falling under these general categories would be considered emergencies:
“Injuries/fractures/contusions” typically require diagnostic imaging to be accurately differentiated and the clinical distinction among them has some emergent importance. The requisite clinical assessment to determine need and extent of imaging, and the imaging studies themselves tend to be either unavailable or only sluggishly so in venues other than an urgent care center or a full service ED

“Abdominal pain” comprises a broad spectrum of potential etiologies that can only be precisely parsed through a comprehensive evaluation by a skilled clinician, and given the scope of such an assessment, generally the resource-rich environment of an emergency department is the most appropriate setting for these evaluations.