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Hospital Admission of Patients with Chronic Disease from the Emergency Department

Posted Aug 11 2009 10:48am

An internist friend surprised me recently by estimating that about half of inpatient admissions at his large academic hospital originated in the Emergency Department. The purpose of many of these admissions is not for acute problems but rather to stabilize the patient and complete a diagnostic work-up that was launched in the ED. The diagnostic problem cannot be completed there because it would take too long and impede the care of other patients with acute problems. Although there are procedures in place to hold such patients for less than 24 hours while still in an outpatient status, this length of time often does not provide sufficient time to complete the work. For many such patients, often put into the category of " alternate level of care (ALC)", there are also out-placement challenges. His experience reinforces the data presented in an article about the Canadian hospital admission experience (see: CIHI Survey: Hospital Admissions via the Emergency Department: Implications for Planning and Patient Flow ). Here is an excerpt from that article:

Over one million Canadians are admitted to hospitals each year via the emergency department (ED). These patients tend to be older, have more severe and multiple conditions or diseases and stay in hospital longer than patients admitted via other means. In 2005-2006, hospital admissions through EDs accounted for approximately 60% of acute care hospitalizations in Canada (excluding hospitalizations in Quebec and those among women admitted for childbirth and infants born in hospital). These patients accounted for 65% of in-patient days, 11% of which were alternate level of care (ALC) days.

The reason for my interest in this topic was a recent note (see: Some Interesting Statistics about the Continuing Growth of Ambulatory Surgery ) in which I speculated about the future composition of hospital inpatients in the following way:

Given that most of oncology care is delivered on an outpatient basis, most inpatient stays will soon be confined to critical care patients, many of them trauma victims, and perhaps end-of-life care. However, many of these latter patients, hopefully, will be served in the future by hospices or by family members in a home setting.

Let me then take this opportunity to correct my previous statement about the mix of patients being admitted and treated in U.S. hospitals. Unless some sort of new way is devised of managing ED patients who are not acutely ill but require an extended diagnostic workup, I suspect that a large category of inpatients will continue to be direct admissions of patients with chronic disease. Of course, there may also be economic reasons why hospitals continue this practice above and beyond the obvious patient management challenges.

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