Although research has focused heavily on increased use of EDs, little attention has been paid to the changing role that these facilities play in the entire healthcare system. In a study published in the New England Journal of Medicine, Arjun Venkatesh, MD, MBA, and I examined the proportion of hospital admissions that came through the ED to determine trends in general use and to confirm the experiences of emergency physicians and hospital administrators in these situations.
ED Admissions on the Rise
Focusing on the 13 conditions for which patients are most commonly admitted to the hospital, our analysis revealed that hospital admissions increased by 15.0%, rising from 34.3 million in 1993 to 39.5 million in 2006, but admissions from the ED increased by 50.4% (rising from 11.5 million to 17.3 million) during that same timeframe. The proportion of all inpatient stays that came through the ED increased significantly, rising from 33.5% to 43.8%. Only one of the 13 conditions studied in our analysis—coronary atherosclerosis— had a proportion that didn’t increase. More and more patients are being evaluated for coronary atherosclerosis in the ED and not admitted thanks to newer rapid “rule-out” protocols and ED-based chest-pain observation units.
Our observation that more admissions are coming through the ED is likely due to several factors, most notably the advancing diagnostic and treatment capabilities of EDs and the convenience that EDs offer. As rapid and accurate diagnoses and treatments become standard, evaluating symptoms like chest pain and shortness of breath have become de facto reasons for ED referral. It has also become more difficult for outpatient providers to admit people directly to hospitals because of the greater demand for administrative efficiency by maximizing occupancy rates.
“Hospital admissions increased by 15.0%, rising from 34.3 million in 1993 to 39.5 million in 2006, but admissions from the ED increased by 50.4%.”
The growth in ED admissions may reflect more timely diagnosis and treatment. Emergency care providers are improving their ability to rapidly diagnose and treat time-sensitive conditions, thus enhancing care for patients. That said, costs can rise significantly if EDs are functioning as the front door for admissions. Many hospitals don’t have operational methods for getting patients into beds rapidly or primary care providers frequently are unavailable.
Admitting patients to hospitals is generally the most expensive decision that physicians can make. We need to identify the critical role that EDs and emergency physicians play in admissions, determine the predictors of admission, and develop programs to manage as many patients as possible as outpatients in a safe and cost-effective manner. With expansions in coverage under the Affordable Care Act, an aging population, and growing expectations for timely care, it’s likely that the trend toward increasing ED admissions will continue. Emergency physicians should view these complex and costly decisions as opportunities to provide better quality care while using resources wisely.
Readings & Resources (click to view)
Schuur J, Venkatesh A. The growing role of emergency departments in hospital admissions. N Engl J Med. 2012;367:391-393. Available at www.nejm.org/doi/full/10.1056/NEJMp1204431.
Tang N, Stein J, Hsia R, et al. Trends and characteristics of US emergency department visits, 1997-2007. JAMA. 2010;304:664-670.
Pitts S, Carrier E, Rich E, Kellermann A. Where Americans get acute care: increasingly, it’s not at their doctor’s office. Health Aff (Millwood). 2010;29:1620-1629.
Newton M, Keirns C, Cunningham R, et al. Uninsured adults presenting to US emergency departments. JAMA. 2008;300:1914-1924.
Asplin B, Rhodes K, Levy H, et al. Insurance status and access to urgent ambulatory care follow-up appointments. JAMA. 2005;294:1248-1254.