New EDBA data from nearly 1000 EDs shows that the emergency department admits at least 68% of inpatient volume
The numbers don’t lie. The emergency department (ED) is the front door to the hospital for the sickest patients, and those that need inpatient service. The 2012 survey results of the Emergency Department Benchmarking Alliance (EDBA) – which compiled data from about 1,000 EDs comprising over 38 million patients – indicate that over 68% of hospital admissions are processed through the ED. This is even higher than estimates published in other recent resource documents. These numbers beg the questions: Why is the hospital’s front door growing, and how important is the “rear door” of the ED, the one that allows admitted patients to flow efficiently to inpatient units?
The EDBA survey began by asking emergency departments to report the percentage of patients that are admitted from the ED to the hospital. This is defined as the percent of patients that are seen in the ED and then placed in an inpatient area of the hospital, either as “full admission” or “observation status”. There is still considerable inconsistency in policies between hospitals, payors (especially CMS), and medical staff members in defining, measuring, and reimbursing between these designations of patients who need service beyond the ED. The EDBA uses the merged number of patients receiving this service, since EDs typically have uniform requirements for designating those patients.
In 2012, about 17% of patients seen in the ED were admitted (Table 1). This percentage has been generally decreasing over the last 9 years. But there is significant variation between the ED volume cohorts. Admission rates are higher in those EDs with larger volumes, and by far highest in EDs serving adults, which admit on average about 25% of patients seen. Those EDs over 40K volume admit over 19% of patients seen, and there are a number of EDs with an admission rate over 30%. Admit rates are about 12% in smaller volume EDs, and about 9% in pediatric EDs.
Next, the EDBA data survey asks about contribution of the ED to the inpatient census. The percentage of hospital admissions that are processed thru the ED is the number calculated from the total of patients that are placed in the status of “admitted” or “observed” status in a hospital from the ED, divided by the overall number of patients that are placed in admission or observation status in the hospital.
In 2012, the EDBA respondents reported that over 68% of hospital admissions are processed through the ED. Table 2 summarizes the data, and indicates that a large percentage of hospitals admit between 60 and 80% of all inpatients through the ED. Consistently through the 9 years of the EDBA survey, the hospitals with smaller ED volumes have the highest utilization for processing patients to the inpatient units. The small community EDs are processing 72% of hospital admissions, and a number of small EDs are managing over 80% of admissions. Smaller EDs also have the heaviest burden of processing patients for transfer to other hospitals, usually for admission. Transfer rates are inversely correlated with hospital admission, and the smaller volume hospitals process over 3% of their patients for admission at other hospitals.
The fact that more than two-thirds of inpatients are processed through the ED would indicate that the general hospital medical staff members are utilizing the ED to provide intensive diagnostic and treatment services, and may feel that the ED is the most effective pathway to process patients into the inpatient environment. Last year’s report by the RAND Corporation on “The Evolving Role of Emergency Departments in the United States” detailed that whether a patient needs to be admitted or not, emergency physicians are providing increasingly comprehensive service to a population with a higher level of complexity, age, and acuity. The report detail states: EDs support primary care practices by performing complex diagnostic workups and handling overflow, after-hours, and weekend demand for care. Office-based physicians increasingly rely on EDs to evaluate complex patients with potentially serious problems, rather than managing these patients themselves. (See accompanying editorial on the Rand Report by Mark Plaster, MD).
Emergency physicians are in many ways the nexus of care for the most critical patient populations and the incumbent financial implications for today’s health care system. Hospitals survive based on patient-care revenue, and emergency physicians are a major contributor to that revenue stream.
Flow, Patient Boarding, and Admission Rates are a “Back Door” Challenge
The ED of any hospital has a fixed number of spaces for patient care, and an ebb and flow with typical cycles across a 24-hour day. ED leaders report progressive difficulty in managing more admitted patients for longer periods of time. This has evolved over about the last 25 years as a problem leading to “patient boarding” and then “ambulance diversion”. The federal government reported on these issues in three US General Accounting Office reports over the last 20 years, and the Joint Commission has written a new standard related to the need for reporting flow of inpatients as a hospital requirement. This year saw the initiation of reporting “boarding time” as an element of the Hospital Compare website.
The EDBA data also indicates there is correlation between long stays for admitted patients, and walkaway rates. This data is undergoing extensive analysis, and will be reported as part of a series of analyses on the flow of EDs related to acuity, volume, use of diagnostic services, and number of patient care spaces. The data will show that longer ED lengths of stay for admitted patients lead to longer lengths of stay for all patients, and a greater propensity for patients to leave before their treatment is complete. This challenges the ED staff to find open space for incoming patients, and leads to the difficulty of keeping walkaway rates from climbing.
Dr. James Augustine is the vice president of the ED Benchmarking Alliance and the Director of Clinical Operations for Emergency Medicine Physicians.
- The Evolving Role Of Emergency Departments in the United States. Morganti, KG, et al. RAND Health, May 2013.
- Emergency Departments: Unevenly Affected by Growth and Change in Patient Use. United States Government Accounting Office. GAO/HRD-93-4. January 1993
- Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities. United States Government Accounting Office. GAO-03-460. March 2003
- Hospital Emergency Departments: Crowding Continues to Occur, and Some Patients Wait Longer then Recommended Time Frames. United States Government Accounting Office. GAO-09-347. April 2009
- National Preparedness: Ambulance Diversions Impede Access to Emergency Rooms. Report of the Special Investigations Division, Committee on Government Reform, United States House of Representative. October 16, 2001
- The CMS Hospital Compare website. www.medicare.gov/hospitalcompare