There Is No Such Thing As An ‘Inappropriate’ Emergency Presentation

On ‘inappropriate’ Emergency Department and ambulance presentations

In my last post (as well as in countless social media posts), I expressed concern about what seems to be a resurgence of “save ambulances for emergencies” messaging and campaigns across my social media feeds. If you haven’t read that post yet, I’d suggest doing so, but the TLDR is essentially that discouraging people from calling ambulances or attending ED may have the desired effect – but we don’t know enough about who will stop presenting to know it is safe.

In making this point, I also mentioned that I have concerns about the use of the term ‘inappropriate’ presentation. In all fairness, ‘concern’ is probably putting it lightly, and what I actually said was:  

I loathe the term ‘inappropriate presentation’, not least of all because defining an ‘inappropriate’ presentation is problematic. In fact, I would contest that there is no such thing as an ‘inappropriate presentation’, only an inappropriately designed health system. The term also implies a failure on the patient’s part, as if somehow, they should have known that the healthcare service they accessed was the “wrong one”.

Terms such as ‘misuse’, ‘unnecessary’, ‘avoidable’ and ‘preventable’ presentation are also common in healthcare, all of which I find problematic to varying degrees. Regardless of which is used, these terms all refer to a presentation to an ED or ambulance service that someone (clinician or otherwise) believes either ‘should’ or ‘could’ have been seen somewhere else, most commonly referring to community-based primary care, such as a GP.

Today’s post is an expansion of my thoughts on these terms, in which I hope to outline more clearly, why, even beyond the use of public messaging to reduce demand, these terms are, at best, inaccurate and, at worst, harmful.

I have framed today’s post through the discussion of ED presentations, but many of the same points are also relevant to ambulance presentations, with the additional consideration that secondary triage mechanisms enable ambulance services to redirect patients without direct patient contact, yet often still do not (see also the post on “Save Ambulances for Emergencies” Campaigns).

The elusive definition of ‘inappropriate’ presentations

One of the issues I raised regarding ‘save ambulances for emergencies’ messaging is that health professionals show little agreement on which presentations are ‘inappropriate’, despite an overwhelming agreement that there is a subset of presentations (to both ambulance services and EDs) that they deem ‘inappropriate’.^1–3 For this reason, I argued that it is unreasonable to expect the public to self-triage when they should seek emergency care.

However, if we set aside the disagreement between clinicians and the subsequent unreasonable expectations placed on the public, we can still consider how ‘inappropriate’ presentations are, or could be, defined and/or identified, perhaps through research, policy, or similar.

In my background reading for this post, I attempted to find the origins of the idea of ‘inappropriate’ ED presentations. While I am not certain if it is the first time the idea was proposed, I did find that the concept dates back to at least the 1960s. In fact, the UK’s renaming of Casualty departments to Accident and Emergency was proposed to help ‘educate’ the public that they should be reserved for emergencies, distancing itself from the ‘casual’ attendee and encouraging GP attendance instead.⁴

More than six decades later, the concept of ‘inappropriate’ presentations remains contentious and without consensus or validation. Despite several definitions being provided, there is little evidence to support that these presentations could have, or even should have, been seen elsewhere.

Most definitions of ‘GP-suitable’ or ‘inappropriate’ presentations rely on one or, more commonly, a combination of the following:^3,5

1. Referral pathway or arrival method
2. Triage score or other measure of acuity
3. Outcome of the clinical presentation

For example, the AIHW uses the term “potentially avoidable GP-type presentations”. These are defined as low-acuity presentations (triage score of 4 or 5) that did not arrive at the ED by GP referral, ambulance, police or corrections (which, I would note, immediately appears to categorise all ambulance attendances as necessary by definition), did not require admission or referral to another hospital, and where the person did not die.⁶ Essentially, this definition combines all of the commonly used metrics.

I have previously outlined why using the outcome of a clinical presentation to determine this is problematic due to hindsight bias. Essentially, my argument here is that if a patient required a full assessment by a clinician to determine whether emergency care was needed, then calling that presentation ‘inappropriate’ or even ‘avoidable’ is disingenuous. If we are going to say a presentation should not have occurred, this needs to be determined before, not after, care is provided.

So, how about using a triage score, presenting complaint, or other means of deciding this prospectively? Is this a valid way to determine who should be seen by a GP instead? After all, the perceived urgency of the problem is also the most commonly used criterion by health professionals to determine who needs care in an emergency department.³

Acuity is a measure of urgency, not need, so let’s stop pretending otherwise

The problem here is that triage is a measure of urgency, not severity, health complexity or health need. It was never designed to determine who needed to be seen in an ED; it was designed to determine the order in which to see those who present.⁷ This makes acuity a poor indicator of the need for unscheduled care, whether that is ambulance or ED care. Many low-acuity presentations will eventually be admitted to the hospital as they need hospitalisation, and many more will receive assessment or treatment in the ED, which may not have been available elsewhere.

Within the literature, attempts to prospectively identify ‘inappropriate’ presentations have not been validated, and I have yet to find any convincing evidence that we can determine who “does not need to be in the ED” using triage, initial clinician assessment, presenting problem or any other information available before thorough clinical assessment. Even with the addition of an initial set of vital signs, none of these factors can be reliably used to determine who could have been seen by their GP, and attempts to do so risk diverting substantial numbers of patients who ultimately require emergency assessment, treatment or admission.⁷

There’s also another key issue here. The entire concept of ‘inappropriate’ or ‘preventable’ presentations rests on the supposed cohort of patients being more suitable for primary care, but for some reason, they weren’t seen by their GP. At least in Australia, this is commonly blamed on a lack of access to GPs.

Primary care isn’t the silver bullet it is presented as

I should start this section by acknowledging the significant issue of access to primary care services currently within many high-income countries, including Australia and Aotearoa New Zealand. There is also a wealth of evidence showing that better access to primary care benefits individual and community health, and is associated with more equitable health outcomes and lower healthcare costs.⁸

Prevention will always be better than a cure. I do, and will continue to, advocate for better and more equitable access to primary care.

The issue I have, however, is the persistence in the media, among health professionals and, most importantly, among health administrators and politicians, of the idea that ambulance or ED demand can be solved solely, or even substantially, by diverting low-acuity patients to primary care at the time of presentation to unscheduled care services.

An important point to note here is that there is no shortage of literature among clinical, epidemiological and health policy journals that claim to show that better access to primary care is the solution. What I find concerning is how little scrutiny this literature receives and how influential it appears to be on policy. Several issues plague this literature base, including small or non-generalisable samples, literature reviews without risk-of-bias or quality assessment, overstatement of findings from retrospective observational studies, and claims of effectiveness that are not supported by the study methodology.

For instance, in my reading, I have found that it is common for claims that better primary care access is the ‘silver bullet’ to be based on methods that retrospectively identify a cohort of patients who supposedly could have been seen by their GP (see the issues with retrospectively determining this above), without actually testing the effectiveness or safety of diversion from an ED or of increased GP access – i.e., they present no actual evidence that primary care works in practice as the solution as it is presented.

However, after applying a bit of scrutiny to the sources we consider, there are several conclusions we can draw from the existing evidence:

1. High-quality evidence supporting interventions to reduce ED presentations is limited, and much of the intervention literature has focused on high-risk or frequent users.^9,10
2. The use of co-located primary or urgent care clinics on hospital sites shows limited evidence of efficacy and cost-effectiveness.^9,11
3. The estimates of so-called primary care suitable attendances are much higher than the observed effects of increased primary care access, and better primary-care quality is associated with modestly lower ED attendance.¹²  

All of this is before we even consider that there is little evidence that low-acuity patients have any meaningful effect on ED overcrowding or ramping – bed block (e.g., EDs being unable to move admitted patients to the ward) is consistently named as the primary contributor.⁹

Acknowledging that the evidence on the causes is thin, there are two other points in the literature regarding the causes and solutions to ED overcrowding that stand out to me.

Firstly, increases in complex or urgent presentations and in presentations by older people are the most commonly cited causes of ED overcrowding related to input (i.e., presentations), rather than low-acuity presentations. Secondly, and for my colleagues here in Australia, this is for you: the most comprehensive systematic review on ED overcrowding I have found contained no Australian studies identifying GP-suitable or low-acuity presentations as a cause of ED overcrowding.⁹

So why do we let our politicians, the media and policymakers continue to blame so-called ‘inappropriate’ presentations for the challenges facing ambulance services and emergency departments?

It’s all just poltical smoke and mirrors

I don’t have an answer to that last question. Anecdotally, I have noticed that it is nurses and paramedics, rather than medical practitioners, who buy into the ‘inappropriate’ presentation myth.

Perhaps, for paramedics, it is because they don’t see the outcome or final diagnosis, making it easy to assume low-acuity presentations should have just seen their GP instead. Or, perhaps it is because, despite ongoing professionalisation of paramedicine and at least three decades of research acknowledging increasing low-acuity presentations within ambulance services, paramedics still have a deep-seated belief that all they should be attending are cardiac arrests, multi-fatality road crashes and whatever else they deem worthy of an ambulance?

Regardless of why this is, it is clear to me that increasing ED and ambulance demand has multiple, complex causes and therefore requires equally complex, multi-pronged solutions. It isn’t caused by so-called ‘inappropriate’ presentations, and it won’t be solved solely by primary care.

Messaging from politicians and health administrators that blames ‘inappropriate’ use of the health system for the challenges it faces has been very effective at one thing – shifting blame without acknowledging or addressing the deep and complex problems in our health systems and broader issues of equity within our communities. It also means that ‘fixes’ focus on big, shiny political promises, rather than doing the hard work of fixing a complex health system and addressing deeper societal inequities related to the social determinants of health.

Final thoughts and comments

I remain unconvinced, despite almost unanimous agreement among some clinicians, that there is any meaningful impact by so-called ‘inappropriate’ presentations, or that there is even any meaningful definition or use for such a term. However, I am worried that by blaming patients for seeking healthcare, we may discourage healthcare presentations or adversely affect patient experience, which can influence outcomes and subsequent help-seeking behaviour, all while failing to recognise the broader issues that lead to low-acuity presentations to our EDs and ambulance services in the first place.

Importantly, so long as health professionals continue to perpetuate the ‘inappropriate’ presentation myth, we are doing our communities a disservice and letting administrators, policymakers and politicians off the hook by buying into distraction tactics of blaming patients rather than a health system that is no longer working.

It is my view that addressing the challenges facing acute health services requires us to look beyond blaming patients and instead engage in meaningful health system reform, seeking solutions rooted in public health, equity, and the social determinants of health.  

As always, stay curious and be excellent to each other.

References

Show References (12)

1.    Prendergast C, Ryan J, Barry LA, Galvin R, Cummins NM. Consensus between healthcare professionals on the “appropriateness” of attendances in an Irish emergency department. Ir J Med Sci. 2025 Jun;194(3):1149–54. https://doi.org/10.1007/s11845-025-03961-0  

2.    Richardson S, Ardagh M, Hider P. New Zealand health professionals do not agree about what defines appropriate attendance at an emergency department. N Z Med J. 2006;119(1232).

3.    Breen BM, McCann M. Healthcare providers attitudes and perceptions of ‘inappropriate attendance’ in the Emergency Department. Int Emerg Nurs. 2013 Jul;21(3):180–5. https://doi.org/10.1016/j.ienj.2012.08.006

4.    Central Health Services Council. Accident and emergency services: Report of the sub-committee of the Standing Medical Advisory Committee (Platt Report). Her Majesty’s Stationery Office; 1962.

5.    Bezzina AJ, Smith PB, Cromwell D, Eagar K. Primary care patients in the emergency department: Who are they? A review of the definition of the ‘primary care patient’ in the emergency department. Emerg Med Australas. 2005;17(5–6):472–9. https://doi.org/10.1111/j.1742-6723.2005.00779.x

6.    National Healthcare Agreement: PI 19–Selected potentially avoidable GP-type presentations to emergency departments, 2022 [Internet]. Available from: https://meteor.aihw.gov.au/content/740847

7.    Raven MC, Lowe RA, Maselli J, Hsia RY. Comparison of Presenting Complaint vs Discharge Diagnosis for Identifying “ Nonemergency” Emergency Department Visits. JAMA. 2013 Mar 20;309(11):1145. https://doi.org/10.1001/jama.2013.1948

8.    Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Q. 2005;83(3):457–502. https://doi.org/10.1111/j.1468-0009.2005.00409.x

9.           Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS ONE. 2018 Aug 30;13(8):e0203316. https://doi.org/10.1371/journal.pone.0203316  

10.  Raven MC, Kushel M, Ko MJ, Penko J, Bindman AB. The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review. Ann Emerg Med. 2016 Oct;68(4):467-483.e15. https://doi.org/10.1016/j.annemergmed.2016.04.015

11.  Ramlakhan S, Mason S, O’Keeffe C, Ramtahal A, Ablard S. Primary care services located with EDs: a review of effectiveness. Emerg Med J. 2016 Jul;33(7):495–503. https://doi.org/10.1136/emermed-2015-204900

12.  Parkinson B, Meacock R, Checkland K, Sutton M. How sensitive are avoidable emergency department attendances to primary care quality? Retrospective observational study. BMJ Qual Saf. 2021 Nov;30(11):884–92. https://doi.org/10.1136/bmjqs-2020-011651