A multitude of non-specific complaints.

Indicators to determine the quality of services in a medical emergency department are most welcome. In order to determine whether they are fit for purpose, comparisons are required. The example of the emergency department of an urban hospital in northern Germany (Fischer/Konitzer; ZfA, abstract 93) shows four times the number of patients/year and the same ratio of further treatment given on an inpatient basis (2/3) and outpatient basis (1/3). The behaviors we observed with regard to referrals and self admissions to the emergency department increased the volume of patients by 20% in the past 5 years, and the trend is upwards. The composition of patients increasingly resembles that of the case distribution seen in primary care practice according to Braun: 20% of unspecific diagnoses (syncope, thoracic pain, chest pain, breathing difficulties, etc) make for 80% of consultations (Pareto function). The primary care “low prevalence” approach relies primarily on “watchful waiting” rather than on the “avoidable dangerous course” approach (the demand for a diagnosis) as the relevant instruction for action vis-a-vis such a multitude of non-specific complaints (1). Translating epidemiology that applies to primary care to the previously “high prevalence” environment of the medical emergency department results in more intense workloads: complaints/symptoms that are allocated to “watchful waiting” become subject to maximum levels of investigations. This shift of emergency department epidemiology may superficially lead to “poorer quality.” The diagnostic agreement (DA) falls with rising occasions of service misuse, if in the event complaints that were initially categorized as serious turn out to be less than serious. The diagnostic efficiency (DE) then falls because of the lower DA and the time consuming investigation of the presenting complaint. The DA and DE thus require epidemiologically based corrective factors in order to do justice to the epidemiology of emergency departments modeled on primary care settings. Correcting misallocated patients may actually require the participation of primary care doctors in the emergency department (2).