The most expensive and dangerous decision in health care is whether to admit a patient to the hospital from the emergency department. Hospital stays cost no less than $1,000 per night (and often much, much more), and bring with them risks like falls, hospital-acquired infections, and medication errors.
With about 100 million U.S. ED visits per year and admission rates ranging from 10 percent to 40 percent, this should be a huge area of interest for the health care community. (Med Care Res Rev 2013;70:218.) The focus on hospital readmissions ignores the even more important question of whether an admission is even what's best for the patient in the first place.
In an ideal world, emergency physicians would only admit patients to the hospital for two reasons:
- The patient's medical condition requires high-intensity services that can only be delivered in the hospital. Cases in point would be a patient needing an emergent appendectomy or a patient with a major heart attack going to cardiac catheterization. These patients are the reason acute care hospitals exist.
- The patient's condition is at high risk for deteriorating, and he needs close observation so we can intervene quickly if things do go south. Patients in this category include those whose stroke symptoms have just resolved (but could come back again) and those whose electrolyte abnormalities place them at risk for cardiac arrhythmias fall into this category.
In the real world, however, patients who really need the high-intensity services of an acute care hospital represent only a fraction of admitted patients. We often admit because:
- A patient is not safe to go home. Every day, EDs are full of 80- and 90-year-olds who fell but are found to have no serious traumatic injuries after a thorough workup. But we can't send them back to an empty house and up a flight of stairs when they are bruised, sore, and unsteady on their feet. What they need is someone to help them in and out of bed and a little bit of physical therapy, but often the only safe environment we have for them is inside the hospital.
- It's less work (for us) than discharging the patient. Most patients who have more than a trivial complaint need some sort of further care and follow-up after their ED stay. The patient with ongoing nausea, vomiting, and diarrhea who is not severely dehydrated or the patient with chest pain after a normal ED workup are good examples. If we send them home, we have to do the work of patient education, writing prescriptions, and making phone calls to ensure good follow-up. If we admit the patient, all of this work goes to the hospitalists. It can be very tempting to pass the buck to the inpatient team when you are five patients behind in your ED.
- Our practice has not kept up with the current state of medical knowledge. EPs care for patients with medical and surgical issues from every organ system related to every specialty. It is impossible to overstate the breadth of medical knowledge required to function even at a basic level in emergency medicine. And we all do things because that is how they were done where we trained, not because they are based on evidence. It is difficult, if not impossible, for us to keep up with all of the literature that allows for things like accelerated diagnostic protocols for chest pain, outpatient treatment for pulmonary emboli, and rules for when to discharge home a patient with a kidney stone.
- We cannot manage patients' and families' expectations. The decision to discharge a patient home is by definition a shared one because it requires the patient to stand up and exit the ED under his own power. We have all taken care of patients with intractable nausea and vomiting who wolf down three turkey sandwiches during their ED stay or with 10/10 abdominal pain who text their way through their fourth normal CT scan this month while insisting they cannot possibly go home. Convincing the worried well to go home takes finesse, and we don't succeed as often as we'd like.
These low-value admissions impose unnecessary risks on our patients, and are a driving force behind the unsustainable escalation in U.S. health care costs. Emergency medicine as a specialty needs to take a leading role in making sure that hospital admissions are reserved for patients who will really get value from inpatient care. We have to design a system where we can demonstrate that doing so will create value for the patient and the provider.
The first step is getting and sharing the data. Institutions like the Emergency Department Benchmarking Alliance publish national statistics about ED admissions rates by size of hospital, and individual emergency departments should be able to generate data about variation within the emergency department. To start a conversation about change, physicians need to see how their own department compares with other similar departments and how they compare with their peers within their institution. Studies often show a twofold variation in admission rates even within an individual department. (Ann Emerg Med 2013;61:638.)
The next step is convincing emergency physicians that some of the patients they have been used to admitting could be better served in the outpatient world. This involves having a conversation about the dangers of admission (falls, infections, etc.) and helping to figure out which patients currently being admitted could be managed as well or better as outpatients. Involving local thought leaders from primary care and other specialties can help emergency physicians better understand who is actually going to benefit from being an inpatient. EPs also need to have easy access to follow-up appointments, accessing home care services, and skilled nursing facility placement 24/7 to make sure that care is being transferred from the EP to an ongoing care team.
Finally, and most often neglected, doing the additional work of arranging for discharge of patients who otherwise might be admitted needs to add value for emergency physicians themselves. Some of the value is intrinsic; fewer admissions should mean fewer ED boarders clogging up the department. The processes for transferring care to an outpatient care team need to be simple, easy, and reliable. This sort of complex discharge planning is a form of uncompensated care, especially for EPs on RVU or other productivity compensation mechanisms. Innovative payment systems supported potentially by global budgets and the system-wide incentives built into ACO plans can share the savings with the providers responsible for creating them.
A refined approach to hospital admissions from the ED has the potential to improve the quality of care, reduce health system expenses, and actually improve the experience and job satisfaction of EPs. But this will only happen if we build systems that provide EPs with the right resources and incentives to take on and succeed at this challenge.
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