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Evaluating emergency department transfers from urgent care centres: insights for paramedic integration with subacute healthcare
  1. Ryan P Strum1,
  2. Fabrice I Mowbray1,2,
  3. Shawn E Mondoux3,
  4. Andrew P Costa1,4
  1. 1Health Research, Evidence and Impact, McMaster University, Hamilton, New Zealand, Canada
  2. 2College of Nursing, Michigan State University, East Lansing, Michigan, USA
  3. 3Medicine, Division of Emergency Medicine, McMaster University, Hamilton, New Zealand, Canada
  4. 4Medicine, McMaster University, Hamilton, New Zealand, Canada
  1. Correspondence to Mr Ryan P Strum; strumr{at}


Objective Paramedics redirecting non-emergent patients from emergency departments (EDs) to urgent care centres is a new and forthcoming strategy to reduce overcrowding and improve primary care integration. Which patients are likely not suitable for paramedic redirection are unknown. To describe and specify patients inappropriate for urgent care centres, we examined associations between patient characteristics and transfer to the ED after patients initially presented to an urgent care centre.

Methods A population-based retrospective cohort study of all adult (≥18 years) visits to an urgent care centre from 1 April 2015 to 31 March 2020 in Ontario, Canada. Binary logistic regression was used to determine unadjusted and adjusted associations between patient characteristics and being transferred to an ED using OR and 95% CIs. We calculated the absolute risk difference for the adjusted model.

Results A total of 1 448 621 urgent care visits were reported, with 63 343 (4.4%) visits transferred to an ED for definitive care. Being 65 years and older (OR 2.29, 95% CI 2.23 to 2.35), scored an emergent Canadian Triage and Acuity Scale of 1 or 2 (OR 14.27, 95% CI 13.45 to 15.12) and higher comorbidity count (OR 1.51, 95% CI 1.46 to 1.58) had added odds of association with being transferred out to an ED.

Conclusion Readily available patient characteristics were independently associated with interfacility transfers between urgent care centres and the ED. This study can support paramedic redirection protocol development, highlighting which patients may not be best suited for ED redirection.

  • Ambulances
  • Ambulatory care
  • Electronic Health Records
  • Emergency department
  • Health services research

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Canadian emergency departments (EDs) are facing a pervasive crisis. In various regions across Canada, hospitals have been forced to close their EDs, or particular services, for a period of time.1 Shortage in healthcare staffing and increased visitation are contributors to this phenomenon, all leading to a healthcare calamity with extensive ED overcrowding.2–4 Ontario is a strong example, reporting its highest-ever wait times to see an ED physician (2.1 hours) and time to admission from the ED (20.1 hours).5

New care models are being prioritised to reduce ED overcrowding and increase integration with primary care services.Using paramedics to transport non-emergent patients to urgent care centres instead of ED’s is probable, though little is known about which patients could be suitable.6 There is negligible research to inform this new paramedicre direction care model, as Canadian paramedics transport exclusively to the ED. Inappropriate ED redirection could result in worse health outcomes and delayed care for time-sensitive clinical conditions, and likely would result in an interfacility transfer to an ED. To support the triage of patients in the community and future redirection protocol development, we evaluated associations between patient characteristics and interfacility transfers from urgent care to the ED.


We conducted a population-based retrospective cohort study by analysing administrative records from the National Ambulatory Care Reporting System (NACRS) database. All adult patients (≥18 years) triaged in an Ontario urgent care centre between 1 April 2015 to 31 March 2020 were included; representing the most recent 5-year period prior to the COVID-19 pandemic. NACRS is a hospital-based and community-based ambulatory care administrative database that collects data on every patient’s urgent care and ED visit at the time of service.7

All patient characteristics included in this study were measured and recorded during the urgent care visit and selected based on the prior literature, clinical judgement and data availability.8 9 Characterises included sex, age, access to primary care, triage acuity, referral source, comorbidities, primary diagnostic category, geographical location and visit outcome. Variables were collapsed into ordinal categories to facilitate model stability when data were non-continuous and small cell sizes (<3% of cohort). Triage acuity was assigned using the Canadian Triage and Acuity Scale (CTAS); an ordinal scale ranging from 1 to 5.10 Main diagnoses were assigned by the attending physician using the International Statistical Classification of Diseases and Related Health Problems, 10th revision. Comorbidities were recorded as pre-existing diagnoses at time of visitand included hypertension, diabetes, chronic obstructive pulmonary disease, asthma, rheumatoid arthritis, congestive heart failure, bowel disease and cancer. Referral source constitutes the service that referred the patient to an urgent care centre, including ambulatory care (ie, physician offices, specialty clinics) or self-referral (patient refers oneself).

Descriptive statistics were reported using measures of frequency and proportions. Multivariable binary logistic regression was used to calculate independent associations between patient characteristics and a visit outcome of transferred to the ED. Results were reported as unadjusted and adjusted ORs of each characteristic with corresponding 95% CIs. Adjusted ORs were used to calculate the absolute risk difference (RD) with 95% CIs.


Table 1 shows the descriptive statistics and analyses of this study. Our cohort contained 1 448 621 urgent care visits, with 1 368 323 (94.5%) visits discharged, 63 343 (4.4%) transferred to ED and 16 995 (1.2%) another visit outcome. Overall, the majority of visitors were female (57.4), younger (18–64 years, 78%) and triaged with either an urgent or less urgent acuity (37.7%; 44.8%).

Table 1

Descriptive statistics, unadjusted and adjusted associations, and absolute risk differences between patient characteristics and urgent care visits transferred to the emergency department (ED) in Ontario, Canada, 1 April 2015 to 31 March 2020

Urgent care visits transferred to an ED were independently associated with the female sex (OR 1.18, 95% CI 1.16 to 1.20), older age (40–64 years, OR 1.38, 95% CI 1.35 to 1.41; 65–105 years, OR 2.29, 95% CI 2.23 to 2.35) and higher triage acuity (CTAS 1 or 2, OR 14.27, 95% CI 13.45 to 15.12; CTAS 3, OR 4.24, 95% CI 4.01 to 4.49). Odds of being transferred to an ED increased with the number of comorbidities (OR 1.07–1.51). Four diagnostic categories showed significant association with ED transfers, including diseases of the digestive system (OR 4.82, 95% CI 4.66 to 4.98) and genitourinary system (OR 1.25, 95% CI 1.19 to 1.30). Overall the area under the receiver operating characteristic curve was 0.84, supporting this adjusted model is an excellent classier of patient characteristics.11


Our results indicate that readily available patient characteristics were independently associated with interfacility transfers between urgent care to the ED. We identify that emergent medical condition acuity, advanced age, multimorbidity and distinct diagnoses could indicate these patients require clinical management beyond urgent care centre resources.These characteristics are consistent with literature describing clinical and non-clinical features connected with essential ED visits.12 13 We postulate other factors absent from this study could be responsible for transfers to the ED, including longer procedural time, need for advanced diagnostic imaging and visits presenting to urgent care centres near closing hours.

The vast majority of patients visiting an urgent care centre have low acuity conditions, of which only a minuscule proportion are transferred to an ED. These data support an argument urgent care centres have the capacity to manage primary care-like conditions effectively. Identification of this patient cohort in the community by paramedics could reduce ED crowding if transported to urgent care centres directly.8 Our findings can inform future paramedic redirection protocols to target younger patients with low acuity conditions that are relatively healthy for redirection from an ED to an urgent care centre. Older adults and patients with specified diagnostic conditions detailed in this study likely require medical imaging not available in urgent care. Additionally, these patients may have more complex conditions or geriatric syndromes, conditions difficult to differentiate in the community or urgent care, and require more definitive ED care.14 Given recent announcements from health policy representatives in Canada regarding implementation of new paramedic transport care models, this work is both timely and important to aid stabilisation of the healthcare system.15 Further research is required to better understand low acuity triaged patients transferred to the ED, and to explore urgent care centres as a means of integrating patients with more primary care.


Paramedics redirecting patients from ED’s to urgent care centres represents a pragmatic strategy to reduce ED overcrowding and congestion. To inform protocol development of a redirection care model, we identify that specified patient characteristics of older age, higher triage acuity, multimorbidity and certain diagnoses were associated with being transferred to an ED from urgent care centres, showcasing a subgroup of patients who may not be suitable.

Ethics statements

Patient consent for publication

Ethics approval

ICES’s collection and use of NACRS secondary ambulatory data are authorised under Section 45 of Ontario’s Personal Health Information Protection Act (PHIPA) as a prescribed entity, which is exempt from review by a Research Ethics Board. The use of the data in this study is authorised under section 45 and approved by ICES’s Privacy and Legal Office.


This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC).



  • Contributors RPS and FIM conceptualised the study objective and methodology. RPS prepared and analysed the data and drafted the manuscript. All authors made contributions to the design of the study, methods, interpretation and manuscript, and agreed to be accountable for all aspects of this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.