Recently in this blog I discussed the increasing resource utilization in the ED. I made the point that, as individuals, we need to include the value, risks, benefits, and costs of all tests, treatments, and interventions. At the organizational level, we should narrow practice variation to where it is supported by evidence and collaborate throughout the care continuum to avoid inappropriate utilization (whatever our relationships to other physician groups or organizations). I noted that, with changing payment structures and incentives/penalties, if we as physicians and physician organizations do not take the lead in these matters, we will either be left behind or be subject to rules created by others, or both.
Interestingly, there are other forces that are conspiring to increase ED utilization and length of stay (LOS). Perhaps counter-intuitively, I do not consider this all bad—in fact, I believe it actually demonstrates the value of EDs and emergency medicine physicians in the changing acute care paradigm. And it is in no way mutually exclusive to providing appropriate utilization and care for specific patients, which we should always do.
The opposing trends that are driving higher ED utilization include older and sicker patients, mandates to decrease admissions, and primary care providers (PCPs) who focus more on health maintenance rather than acute care. We in the ED are seeing more complex patients, and what is considered appropriate care in the ED has expanded. For example, recent studies (e.g. RAND Corp, The Evolving Role of Emergency Departments in the United States) confirm that PCPs are increasingly referring acutely ill or injured patients to the ED for expedient evaluation and management.
My physician group is rightly focused on decreasing ED LOS for admissions and discharges. Clearly, improving the efficiency of operations and searching for innovative “game changing” solutions is imperative. However, the ability to impact these metrics by improving efficiency is limited by the changing ED patient mix. In the short term, I do believe that there is slack in the system and that we will be successful in reaching our metric goals. Longer-term, however, we may well see increases in ED LOS despite our best efforts. We need to be cognizant of this possibility and not necessarily consider it a failure.
ED physicians may need to evolve their concept of appropriate ED care. For the reasons listed above, we will very likely be providing more care rather than less in the ED. For example, admissions that would have been a “slam dunk” in the past are likely to require extensive ED workups and treatments and to result in an outpatient disposition. Lee, et al in Annals of EM recently calculated that emergency care may come to represent 5-6% of the nation’s health care expenditures, rather than the traditionally quoted 2%.
Increased utilization of the ED, however, may not be a bad thing. In fact, I think it simply validates the importance of the field. The ED, with the 24x7 availability of physician and nursing expertise and the diagnostic and therapeutic resources with underlying fixed costs, is actually the ideal place in the healthcare system to care for patients who legitimately need it. While a child with otitis media may best be treated in an outpatient facility, the older, sicker, more complex patient belongs in a well-equipped ED. However, a growing influx of these patients into the ED means that emergency physicians will ultimately need more help and collaboration from consultants and case management.
We must recognize these trends in our healthcare system and the potential impact upon our emergency departments. I see this as a great opportunity for EM. The push to reduce ED use makes sense only when it refers to reduction of unnecessary use. There are people who do need the resources of the ED, and with the aging Boomers generation, the number will increase. Emergency departments are integral to the entire healthcare system and provide an essential, expanding, and cost-effective service for patients. If we recognize and adapt to these changes in demand and compensation, as well as to advances in treatment, organization, and technology, we will only become more valuable in the future.