OPERATIONS MANAGEMENT COMMITTEE
Avoiding Emergency Department Admissions: The Why and How Tom Scaletta, MD MAAEM, Akiva Dym, MD FAAEM, and Anthony Rosania MD MHA FAAEM
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n the United States, approimatly 30% of adult emergency department (ED) patients are admitted, and three-quarters of all hospitalized patients originate in the ED. An emergency physician (EP) hospitalizes approximately six patients on an average shift. However, when one patient is safely discharged from the ED instead of being admitted, about 40 hours of inpatient human resources are conserved, which is especially important during this unprecedented nursing shortage.1 Furthermore, given the scarcity of staffed inpatient beds, reducing unnecessary admissions reduces ED boarding and thus improves overall ED throughput and performance. The opportunity cost of boarding can be high, and reducing unnecessary admissions can provide significant financial, operational, and human resource savings to the ED and the entire hospital system. More than half of Medicare patients are enrolled in Medicare Advantage, a program that shifts reimbursement from fee-for-service to capitation.2 With capitation, payment for health care services is based on value (high quality and low cost) rather than volume. It is expected that Blue Cross, Humana, Cigna, Aetna, Anthem, and United Healthcare will expand value-based payments across all their product lines. CVS, Walgreens, Amazon, and Walmart are currently evaluating capitated health care models.3 As such, it is thus critical to reduce unnecessary hospitalizations to prevent excess costs which may be preventable.
is consistent with previously reported ranges of ED admission rates.4 The lowest admitter ordered 35.2% fewer advanced radiology studies, prescribed 49.1% fewer antibiotics, and 35.5% fewer opiates. He generated 11% more RVUs per hour and discharged patients 44 minutes faster. However, his patient satisfaction scores were lower as compared to his peers. No correlation was found between admission rate and the number of medical malpractice claims, cases referred for quality review, or rate of patient returns within three days of ED discharge. Normalization of the ED emergency severity index (ESI) data was performed to exclude the practice of “cherry-picking” cases as a potential explanation for the wide admission rate range. The respective admit rates by ESI for the lowest and highest admitters were 40.0% versus 67.9% for ESI-2 cases (emergent), 11.8% versus 34.6% for ESI-3 (urgent) cases, and 0% versus 1.5% for ESI-4 (non-urgent) cases. What is the impact of this wide range of admission rates on the ED and hospital? If the EP with the highest admission rate shifted to the mean admission rate, it would translate into two fewer patients being admitted per shift worked. In addition to the significant cost and time savings of reduced admissions, judicious admitting also reduces hospital-acquired infections, episodes of sundown syndrome, mortality in older chest pain patients, and 30-day rehospitalizations, a metric of Medicare Advantage reimbursement.6 Additionally, it is intuitive that admissions that can be safely avoided are lower acuity. So a more conservative approach to admissions will positively impact a hospital’s case-mix index, or CMI, which can lead to increased Medicare reimbursement. Judicious admitting practices also reduce the chance that a recovery audit contractor (RAC) will report concerns to CMS. Such investigations occasionally force corrective action plans that disrupt business operations and hold back Medicare payments. Furthermore, patients should be informed of the risks associated with admission and participate in shared decision-making regarding their disposition, as most prefer to go home.
Patients should be informed of the risks associated with admission and participate in shared decision-making regarding their disposition, as most prefer to go home.
As a case study, ED visits were analyzed at the author’s large, suburban ED, with an annual volume of approximately 80,000 visits. During the fourth quarter of 2022, there were 20,341 ED encounters. A total of 4,668 cases were seen by a pediatric EP and excluded from this study. Of the 15,673 remaining encounters (92% adults), the average admission rate was 30.3%, with a range of 19.7%-41.9%. This data
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COMMON SENSE MARCH/APRIL 2023
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