Admission Variability in the Emergency Department

Authors: Adam J. Rodos, MD (Assistant Professor – Clinical Emergency Medicine, University of Illinois Hospital & Health Sciences System) and Timothy J. Meehan, MD, MPH, FACEP (Assistant Professor – Clinical Emergency Medicine & Medical Toxicology, University of Illinois Hospital & Health Sciences System) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Stephen Alerhand, MD (@SAlerhand)

We have all been there. You start your shift by receiving sign-out from your overnight colleague, listening as you hear about the 30 year-old in Room 5 without any cardiac risk factors being admitted for serial enzymes, “just to be safe.” Or the sick bounce-back that after reviewing the initial ED visit, makes you shake your head while wondering how anyone could have discharged that patient. As emergency physicians, we are used to operating in the gray area, something never as evident as when it comes to patient disposition from the ED. Understanding how we arrive at this decision has important implications for medico-legal liability in our current tort environment, for reimbursement in the post-ACA landscape, and most importantly for patient safety.¹ How do EPs arrive at the admit-versus-discharge decision?

Wu et al. define the issue of patient disposition as follows: “Disposition of ED patients should be optimal and accurate and made according to the disease severity and diagnosis, based on current medical references and evidence-based medicine.”² This definition states all the right things, though it leaves little guidance as to how it should be applied.

For example, a retrospective observational study from the LDS Hospital Emergency Department published in 2012 reviewed admissions and outcomes data for 2,069 patients diagnosed with pneumonia in the ED between 1996 and 2006.³ Admission rates varied from 38% to 79%. The ED physician who saw the patient remained an independent predictor of admission even when controlling for disease severity. Patient characteristics alone did not account for this difference in admission variability.  Importantly, higher hospitalization rates were not associated with reduced mortality or fewer secondary admissions.  This suggests that Wu’s definition is not being appropriately applied.

However, Wu does not comment upon physician experience in making this decision. Calder, et al, attempted to do so by looking at how emergency physicians make discharge decisions.⁴ Their cohort of physicians reported relying on clinical judgment rather than evidence-based decision rules, citing vital signs, resolution of chief complaint, and normal results of investigations performed in the ED. While only a few adverse events were identified in this small study (10/366 discharges, 2.7%), the identified events were all deemed to have been preventable. These authors defined a preventable adverse event as a diagnostic issue, management issue, unsafe disposition decision, or sub-optimal follow-up. Though they determined that the adverse events were preventable, it is far more difficult to study how many unnecessary admissions would be required to prevent those adverse events, and how many adverse events might be associated with those admissions.

Another study looked more generally at all the disposition decisions for emergency department patients in an ED in Taiwan.² The more experienced the ED physician, the more likely the patients they cared for were to be admitted to the hospital. This remained statistically significant even when controlling for acuity, patients seen, etc. Does this suggest that our more “seasoned” colleagues know something more about this debate? They have seen the low-risk chest pain return in cardiogenic shock and the well-appearing pyelonephritis patient re-present in septic shock.

Calder et al. used focus groups to create a model of the emergency department discharge decision using key stakeholders including physicians and residents, nurses, social workers, and administrators.¹ Key determinants of disposition decision across all focus groups included triage location and location of patient assessment, the so called “geography is destiny” maxim.⁵ Other themes that emerged included social/patient factors, risk stratification, and clinical gestalt. As evidenced by this consensus focus group map, the disposition decision is not exactly straightforward. Though we often think of the disposition decision lying solely within the realm of the emergency physician, there appears to be more team input and influence than one might have expected.

           Calder et al. Ann Emerg Med. 2012;60(5):567–576.e4. 

During the focus groups, it was noted that the participants prioritized avoiding unsafe discharges rather than unnecessary hospitalizations. We worry far more about the elderly patient we discharged from the ED having an untoward outcome than we do about admitting that same patient and that patient falling or developing delirium.

Perhaps no decision we make is fraught with more peril than that of clicking discharge. What are we, as emergency physicians, to do with this information?

1. We can recognize the complexity of the decision and that numerous stakeholders are involved, making a point to include our nursing and social work colleagues in the discussion in those cases when we are truly unsure of the best way to proceed. It may be the nurse or social worker that can provide that key piece of information (the two flights of stairs that must be climbed at home, the fact that the reliable wife actually seems quite forgetful) that clarifies the right path.
2. We can remember that a hospital admission carries its own set of risks. These risks need to be tracked and better quantified so we know how to best factor these into our disposition decisions. When we are trying to convince a patient that they are best served by staying out of the hospital, we might mention the risk of nosocomial infection or fall, but how well do we understand these risks? As the literature notes, simply admitting more patients does not protect the patient from the very morbidity and mortality that we think we are preventing when we pick up the phone to sign-out that admission. ^2-4
3. We can harness our EMRs to provide data to drive change. On the national level, development of clinical decision guidelines can help us minimize unnecessary variance in our disposition decisions. Locally, compare your data with that of your physician colleagues. If you admit 3x more CHF patients than the rest of your group, maybe you need to rethink your practice. Work with your specialist colleagues to develop local protocols to guide your disposition of low-risk chest pain or GI bleeding, recognizing that these serve only as a guide and there will be times when the patient with a non-existent HEART score still warrants hospital admission.
4. We can utilize appropriately validated clinical decision rules to guide disposition decisions. Especially in those cases in which we are “on the fence” as to whether a patient should be discharged home versus admitted. Medico-legal risk has been suggested to be a strong driver of the admission process and utilization of clinical practice guidelines offers the potential to mitigate this risk.^6-7

We take our responsibility for the safe disposition of patients very seriously, yet as much as we debate the best initial fluid for sepsis resuscitation, the most effective way to ventilate after percutaneous cricothyrotomy, or the optimal technique for reduction of the dislocated shoulder, we talk far less about how to disposition our patients. This falls into the gray area of EM – an unwritten curriculum in residency, learned “in the pit” with little to no formal dedicated time. As the patient disposition process is among most important aspects of every patient encounter, more resources ought to be devoted to its study.

References/Further Reading

1. Calder LA, Forster AJ, Stiell IG, et al. Mapping out the emergency department disposition decision for high-acuity patients. Ann Emerg Med. 2012;60(5):567–576.e4. doi:10.1016/j.annemergmed.2012.04.013.
2. Wu KH, Chen IC, Li CJ, Li WC, Lee WH. The influence of physician seniority on disparities of admit/discharge decision making for ED patients. Am J Emerg Med. 2012;30(8):1555–1560. doi:10.1016/j.ajem.2012.01.011.
3. Rosenthal GE, Harper DL, Shah A, Covinsky KE. A regional evaluation of variation in low-severity hospital admissions. J Gen Intern Med. 1997;12(7):416–422. doi:10.1046/j.1525-1497.1997.00073.x.
4. Calder L a, Arnason T, Vaillancourt C, Perry JJ, Stiell IG, Forster AJ. How do emergency physicians make discharge decisions? Emerg Med J. 2013:9–14. doi:10.1136/emermed-2013-202421.
5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775–780. doi:10.1097/00001888-200308000-00003.
6. Garnick DW, Hendricks AM BT. Can practice guidelines reduce the number and costs of malpractice claims? JAMA. 1991;266:2856–60.
7. Katz DA, Williams GC, Brown RL, et al. Emergency physicians’ fear of malpractice in evaluating patients with possible acute cardiac ischemia. Ann Emerg Med. 2005;46(6):525–533. doi:10.1016/j.annemergmed.2005.04.016.