• Gabor D Kelen, Chadd K Kraus, Melissa L McCarthy, Eric Bass, Edbert B Hsu, Guohua Li, James J Scheulen, Judy B Shahan, Justin D Brill, and Gary B Green.
• Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21287, USA. gkelen@jhmi.edu
• Lancet. 2006 Dec 2; 368 (9551): 1984-90.

BackgroundThe ability to provide medical care during sudden increases in patient volume during a disaster or other high-consequence event is a serious concern for health-care systems. Identification of inpatients for safe early discharge (ie, reverse triage) could create additional hospital surge capacity. We sought to develop a disposition classification system that categorises inpatients according to suitability for immediate discharge on the basis of risk tolerance for a subsequent consequential medical event.MethodsWe did a warfare analysis laboratory exercise using evidence-based techniques, combined with a consensus process of 39 expert panellists. These panellists were asked to define the categories of a disposition classification system, assign risk tolerance of a consequential medical event to each category, identify critical interventions, and rank each (using a scale of 1-10) according to the likelihood of a resultant consequential medical event if a critical intervention is withdrawn or withheld because of discharge.FindingsThe panellists unanimously agreed on a five-category disposition classification system. The upper limit of risk tolerance for a consequential medical event in the lowest risk group if discharged early was less than 4%. The next categories had upper limits of risk tolerance of about 12% (IQR 8-15%), 33% (25-50%), 60% (45-80%) and 100% (95-100%), respectively. The expert panellists identified 28 critical interventions with a likelihood of association with a consequential medical event if withdrawn, ranging from 3 to 10 on the 10-point scale.InterpretationThe disposition classification system allows conceptual classification of patients for suitable disposition, including those deemed safe for early discharge home during surges in demand. Clinical criteria allowing real-time categorisation of patients are awaited.

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