“Pharyngitis/strep” may be initially evaluated in almost any medical facility, but the typical rapid onset of symptoms coupled with uncertainty of potential adverse short-term evolution and lack of access to other venues accounts for many, if not most ED visits for this complaint. Certainly, more complex or severe cases or those with airway-threatening complications are appropriate only for the full-service setting of an ED. And, in gauging relative costs of ED versus alternative setting care, as pointed out by Smulowitz et al, “even without taking into account the additional cost of treating some of the lower-severity conditions in an alternative setting, it would require diverting more than 80 patients with pharyngitis to save the money equivalent to a single avoided hospitalization.”

“Respiratory infections” again constitute an array of potential diagnoses, many of which require the in-depth ancillary testing available only in an ED. From a patient perspective, understandable uncertainty of underlying causes and potential for adverse evolution are often drivers of the decision to seek care in an ED. Here again, retrospective application of a discharge diagnosis of “URI” or “bronchitis”, will fail in a substantial number of cases to differentiate between true “emergency” presentations versus those that might be considered “nonemergency” visits.

“Vomiting,” while most often of benign cause in the pediatric population, is a source of serious concern for parents and carries an immediacy of evaluation and management. Many cases seen in the ED have already received phone counseling or prescriptions from a primary care provider, or have been the subject of “watchful waiting” or home remedies prior to coming to the ED. The differentiation of benign causes such as viral gastroenteritis from more serious underlying conditions such as intussusception can often only be made after a thorough clinical evaluation coupled with more or less extensive ancillary testing.

“Bronchitis” should rightfully be included in the above “respiratory infections.”

“UTIs” are relatively common and require at least some ancillary testing for diagnosis. Here again, the need for testing and relative lack of other available venues are likely the principal drivers in seeking care in an ED.

As to the question of what percentage could have waited to see the PCP, this is obviously indeterminate in a prospective fashion. Many cases seen in the ED are in fact referred by the PCP due either to lack of scheduling flexibility, diagnostic uncertainty, need for ancillary testing, or in some cases simply as a use of the “Easy” button to avoid non-routine unscheduled office visits.