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Emergency Physician-Driven Admission Decisions Reduce Crowding

May 5, 2020

Written by Clay Smith

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Emergency physician (EP) determination of the need for admission, vs. getting approval from a consultant first, was extremely accurate and would have significantly reduced ED wait times and crowding.

Why does this matter?
In some hospital systems, like this one in Canada, if the EP wants to admit a patient, they must ask a consultant to see the patient, agree that they need admission, and only then admit the patient. See figure below. What if, in these hospitals, the EP made the decision to admit when they thought the patient needed admission?

Call it from the door…
This was a single center, prospective study in Canada over a 5 month span. EPs were asked what disposition decision they would make just prior to the consultant seeing the patient. This was a convenience sample, which excluded high acuity (e.g. STEMI, stroke) patients with obvious need for admission. If the EP had made the admission decision, instead of waiting for the consultant, it would have saved patients a total of 922 hours languishing in the ED over this 5 month period. Also, EPs got it right and, “correctly predicted 92.8% of patient admissions.” Sensitivity, specificity, positive predictive value and negative predictive value were 90.5%, 84.2%, 92.8%, and 79.6%, respectively. Predicting psychiatry admission dragged down the overall numbers a bit. When considering just general surgery admissions, the EP was correct (i.e.PPV) 90% of the time; for general internal medicine, 95.7% of the time; other surgical (i.e. ENT, neurosurgery, plastics, trauma), 94.7%; other medical (i.e. heme, GI, ID, renal), 100%. There was strong agreement between the EP and consultant for all disposition decisions, kappa 0.885. This study suggests that this simple practice would reduce crowding and wait times.

Adapted from cited article

Using emergency physicians’ abilities to predict patient admission to decrease admission delay time. Emerg Med J. 2020 Mar 5. pii: emermed-2019-208859. doi: 10.1136/emermed-2019-208859. [Epub ahead of print]

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