The purpose of this study was to assess whether referral to a pediatric emergency department (PED) by a primary care provider was associated with greater severity of illness, as determined on the basis of clinical measures and increased resource utilization.


A retrospective study of data for 121 088 children who presented to a PED with abdominal pain, fever, or respiratory complaints during a 5-year period was performed. Demographic data, referral status, and proxy markers of illness severity were collected from the medical records and analyzed.


A total of 26.3% of all patients seen in the PED presented with these 3 complaint categories. With adjustment for age, gender, race, and insurance class, referred patients were significantly more likely to have high triage acuity designations, higher rates of very abnormal vital signs, and higher admission rates, compared with patients who were self-referred. Referred patients were more likely to undergo testing (laboratory or radiologic), to receive intravenous fluid therapy and pain medications, and to be assigned higher-severity discharge diagnoses, such as appendicitis, septic shock, or status asthmaticus.


Referral by a primary care provider to a PED was significantly and independently associated with greater severity of illness and resource utilization. Referral status should be considered in algorithms used to triage cases for evaluation in the PED.

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