For 10 terrifying minutes, Vincent, 58, lost the ability to speak. His wife, Linda, rushed him to the emergency department, convinced he was having a stroke. In the car on the way to the hospital, Vincent started talking again. But Linda continued to the ED. “You need to get checked out,” she insisted.
Vincent’s doctor faced a dilemma. On one hand, Vincent was now making jokes, teasing the staff, and seemed perfectly well. The physician’s first instinct, after initial testing was reassuring, was to discharge him for close follow-up and additional testing at an outpatient neurology clinic. But would Vincent be able to schedule a next-day appointment? Would the testing be done expeditiously? What if after meeting resistance, he skipped the follow-up altogether?
To be on the safe side, the physician decided to admit Vincent and conduct a full workup in the hospital. Because the inpatient unit was full, Vincent spent a sleepless night in the ED. The next morning, Linda drove 25 miles home to go to work. Two days later, when Vincent was discharged, she took a day off and drove 50 miles round trip to pick him up. This short hospital stay cost Vincent and Linda $1,400 out of pocket in addition to gas costs and lost wages.
Vincent’s story illustrates an emerging issue for health systems. Today’s hospitals are treating a sicker patient population that consumes more resources. To relieve the pressure, lower acuity patients like Vincent could be managed in the community. However, without systems of support in place, physicians are reluctant to release patients into the healthcare maze. This all adds up to a looming capacity crisis that could redefine acute care as we know it.
For the past decade, ED volumes have been growing slowly but steadily. Every year, we’ve seen millions more patients than the previous year. Fortunately, this growth is slowing as more patients turn to primary care and telehealth to meet their needs. But unfortunately, with copays and deductibles on the rise, one in four Americans now skips care due to its cost.
For EDs, this means the post-COVID-19 patient mix will look nothing like the pre-pandemic mix of 2019. Moving forward, departments will likely care for sicker, older, and all-around less well patients than ever before. Interestingly, this difference can’t be explained entirely by COVID-19. Our heart attack patients will be sicker, our stroke patients will be sicker, and even our abdominal pain patients (a group that includes younger people) will be sicker.
The data suggest this shift is well underway. In emergency medicine, we measure patient acuity using the Emergency Severity Index (ESI). On this scale, 1 represents our most acute patients, while 5 is assigned to the least sick. Throughout the pandemic, we have seen the number of lower acuity patients—ESI 4s and 5s—decline or stabilize. At the same time, volumes of ESI 1s and 2s have skyrocketed by 20% to 50%.
Rising admission rates also reflect an uptick in acuity. Before COVID-19, a common admission rate from a community ED was 15%-18%. Today we’re seeing 17%-20% admitted—and sometimes even higher.
This trend impacts not only the ED but all areas of the hospital. Case mix index, an inpatient measure of acuity, has been rising within Vituity and (I expect) other providers as well. So, in addition to the ED, inpatient and surgical services departments also need to prepare for a “super acute” future.
To adjust to this new high-acuity patient mix, health systems must plan for both short-term realities and long-term sustainability.
In the short term, departments may need to adjust staffing ratios and resource allocation. Decisions can no longer be based on patient numbers alone. Clinical leaders must also account for acuity in their calculations. As a hypothetical example, an ED that provided, say, 3 hours of direct care staffing per patient in 2019 might need to increase to 3.2 hours of staffing in 2022. Clinicians who were staffed to see 2 patients per hour in 2019 may want to staff for 1.8 or 1.9 per hour.
Clinical leaders also need to think about skillset distribution. For example, we need to make sure we hire staff capable of managing complex patients and reinforce advanced skills during onboarding. With the loss of older nurses as part of the “Great Resignation,” the incoming workforce will have less experience and might need different accommodations, with higher levels of supervision and on-the-job training.
However, injecting more resources into hospitals isn’t a long-term fix and isn’t sustainable for most health systems. To accommodate sicker patients, we will need to adapt our entire delivery system to provide a higher level of care in the community. In other words, we need to strengthen outpatient support networks so that physicians can confidently discharge lower-risk patients like Vincent.
Clinicians know how hard it is for patients to navigate the healthcare system. They often feel it’s safer to admit someone or keep them in the hospital an extra day. However, from a cost and resource standpoint, we need to find new ways to manage higher acuity patients at home—including many who historically would have been hospitalized. The more care we can deliver in place, the more sustainable and effective our health systems will be.
Every ED sends home patients who are borderline—unwell, but not quite sick enough to admit. Given the global rise in acuity and admission rates, we can reasonably assume that EDs are discharging more high-risk patients than they have in the past.
To ensure patient safety, we must therefore develop new networks of care. For example, we can use care navigators to guide patients through the confusing outpatient medicine system. Hospital-at-home programs are another way to extend care into the community. Under this model, hospitals expand capacity by managing lower acuity patients via telemedicine and mobile nursing and ancillary teams.
When a hospital is overwhelmed with admissions, caring for some patients at home is often more cost-efficient than adding physical space and beds. Existing med-surg beds can then be converted to telemetry beds to accommodate more higher acuity patients within the hospital walls.
Unfortunately, when it comes to adapting for a super acute patient mix, health systems don’t have the luxury of time. The data show that acuity is actively rising. The sooner hospitals can recalibrate to this reality, the less disruption they will face to their long-term operations.
On the bright side, we’re probably overdue for a shift toward outpatient care. New technologies and treatments make virtual care safer and more effective than ever before. Community-based treatment models are generally more cost effective than caring for patients in-house. And perhaps best of all, when we care for patients in place, we often improve the quality of their lives.
In a way, medicine is returning to its roots, when physicians made house calls. While our modern visits may be virtual, they allow us to spend more time with lower acuity patients like Vincent, connect more deeply, and therefore bring greater satisfaction and meaning to our careers.