Hospitals and an Innovative Emergency Department Admission Process

Eric E. Howell, MD; Edward S. Bessman, MD; Haya R. Rubin, MD, PhD

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Abstract and Introduction

After treatment in an emergency department (ED), patients often wait several hours for hospital admission, resulting in dissatisfaction and increased wait times for both admitted and other ED patients. We implemented a new direct admission system based on telephone consultation between ED physicians and in-house hospitalists. We studied this system, measuring admission times, length of stay, and mortality. Postintervention, admission times averaged 18 minutes for transfer to the ward compared to 2.5 hours preintervention, while pre- and postintervention length of stay and mortality rates remained similar.

Emergency department (ED) visits and patient acuity have steadily increased throughout the last decade, leading to a greater percentage of patients admitted to the hospital.[1] Correspondingly, ED congestion and length of stay (LOS) have worsened, with admitted patients often waiting several hours for transfer out of the ED after treatment.[1,2] In addition to dissatisfying patients, this also increases the LOS of ED "treat-and-release" patients.[3] Many hospitals rely on physician staff from departments outside of the ED, or "consultants," to evaluate and admit patients from the ED, contributing to admission delays.[4] Removing consultants from the process and having the ED triage and transfer patients directly to inpatient hospital services can reduce admission delays.[4] This strategy precludes what may be valuable input from consultants prior to the admission. Hospitalists may represent a solution to this problem; the use of hospitalists (inpatient-based attending physicians) has exploded recently, with 5,000 practicing in the United States currently and an estimated 20,000 practicing in 10 years.[5] Using hospitalists, we designed an admission process that combines the advantages of consultant participation with that of rapid direct admissions. This is accomplished by having ED physicians admit patients directly to the general medical unit after a telephone consultation with a hospitalist. We evaluate this process using a prepost comparison of the time from ED decision to admit a patient until the time the patient arrived on the medical service (hereafter called "admission cycle time"), hospital LOS, and in-hospital mortality rates.

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