Emergency Department Triage: Deciding Hospital Admission vs. Discharge

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• Key Factors for Hospital Admission
• The Hospital Admission Process Explained
• Emergency Department Overcrowding Challenge
• Understanding Patient Boarding in the ER
• EMTALA Law Impact on Emergency Care
• Systemic Solutions for Emergency Medicine
• Full Transcript

Key Factors for Hospital Admission

Dr. Sam Shen, MD, outlines the primary reasons a patient is admitted to the hospital from the ER. The main reason for admission is a requirement for 24-hour medical monitoring. Patients should stay if they need a specific service unavailable at home.

Dr. Sam Shen, MD, explains that a patient may be too sick for home care. Admission is also necessary if a patient cannot independently care for themselves. A lack of appropriate support at home is another critical factor in the admission decision.

The Hospital Admission Process Explained

Dr. Anton Titov, MD, discusses the process after an admission decision is made. The emergency medicine physician contacts the appropriate hospital specialty service. This could be internal medicine, orthopedic surgery, or neurosurgery.

Once a service accepts the patient, they are formally admitted. A typical hospital stay from the ER lasts two, three, or four days. This process ensures the patient receives specialized care for their condition.

Emergency Department Overcrowding Challenge

Dr. Sam Shen, MD, identifies overcrowding as a major challenge for emergency medicine. The number of hospitals has decreased over the last 20 to 30 years. This reduction means fewer Emergency Departments are serving a growing population.

Hospitals and their ERs now operate at maximum capacity. It is not uncommon to find patients receiving treatment in hallways. This congestion directly impacts the quality and timeliness of emergency medical care.

Understanding Patient Boarding in the ER

Dr. Shen describes "boarding" as a critical national problem. Boarding occurs when an admitted patient cannot move to an inpatient bed. These patients must wait in the Emergency Department, often for hours.

This situation increases the risk of medical complications for patients. The goal of the ER physician shifts to facilitating a faster transfer upstairs. Getting the patient to the appropriate specialty service becomes a top priority.

EMTALA Law Impact on Emergency Care

Dr. Anton Titov, MD, and Dr. Sam Shen, MD, discuss the federal EMTALA law. This law mandates that ERs receiving government funds must accept all patients. They must provide a medical screening exam to everyone seeking care.

This ensures excellent access to emergency medicine regardless of financial status. The downside is that it strains limited ER resources. Overcrowding is often a direct result of this unfunded mandate.

Systemic Solutions for Emergency Medicine

Dr. Sam Shen, MD, connects overcrowding to broader systemic issues. A lack of health insurance forces many to use the ER for primary care. Poor access to primary care physicians is a significant contributing factor.

Hospitals are working on strategic solutions to ease congestion and boarding. Improving patient flow and inpatient discharge processes is crucial. Addressing these complex, multi-factorial problems is essential for improving emergency care quality and patient experience.

Full Transcript

Dr. Anton Titov, MD: Emergency medicine: stay at hospital or go home? This is a key decision that an emergency medicine physician has to make for each patient. What are the decision rules to admit patients to the hospital or send a patient home?

What are the challenges facing Emergency Departments in the better treatment of patients? How to deal with boarding and overcrowding in the Emergency Department? Which patients should stay, and which patients should go home?

Emergency medicine: stay at hospital or go home. A video interview with a top expert in Emergency Medicine. A significant problem in US emergency medical services is overcrowding and boarding. Patients who are admitted to the hospital cannot go to their service because there are not enough beds.

Hospitals are trying to cope by faster inpatient discharges. A medical second opinion helps to make sure a preliminary diagnosis is correct. A medical second opinion also helps to choose the best treatment for your medical condition before it becomes an emergency.

Seek a medical second opinion on your medical problem to avoid a visit to the Emergency Room later. There is a federal law in the US called "EMTALA". It says that Emergency Departments must accept all patients who seek medical care. This is great for access to medical care, but it leads to Emergency Department overcrowding.

Dr. Anton Titov, MD: Sometimes a patient is admitted to the Emergency Medicine department. An emergency medicine physician evaluates the patient and orders medical tests. What are the important factors to decide whether the patient should go home or get admitted to the hospital?

What are the challenges that the Emergency Medicine system in the US faces?

Dr. Sam Shen, MD: To decide if the patient can go home or needs further care in the hospital is an important decision. The main reason for a patient to stay in the hospital is the requirement for 24-hour monitoring.

Patients should stay in the hospital if they require a particular service that cannot be provided at home. Or if the patient is just too sick to be cared for at home. Or if the patient is not able to independently care for themselves at home.

Or if the patient does not have the appropriate support around them to assist. The Emergency Medicine physician makes a decision to admit the patient to the hospital. Then the emergency medicine physician talks to the hospital specialty service that is going to admit the patient.

For example, Medicine, Orthopedic surgery, or Neurosurgery. Sometimes the patient is accepted to the hospital by the appropriate service. Then the patient will stay for two, three, or four days typically.

Emergency Medicine departments have two main challenges in recent years. One challenge is overcrowding. Another challenge is called "boarding". In the last 20 or 30 years, the number of hospitals has decreased.

Fewer hospitals means fewer Emergency Medicine departments. There are more and more patients who try to get treatment at fewer and fewer Emergency Departments. You have a situation where a growing population tries to get medical service at fewer Emergency Departments.

Hospitals and Emergency Departments are working at maximum capacity levels. It is not uncommon to see sometimes patients in the hallways. More and more patients are in the medical system, so it creates congestion.

The patient could already be admitted to the hospital. But the patient cannot go upstairs to their inpatient bed because there are too many patients in the hospital. The patient has to "board" in the Emergency Department.

This situation, "boarding", is a challenge nationally. Many hospitals are trying to strategically solve the problem of congestion and patient boarding. We understand that if patients are staying too long in the emergency department while waiting for their bed upstairs, the rates of complications rise.

We made the decision to admit the patient to the hospital. The next goal of the Emergency Department physician is to facilitate the process of getting the patient upstairs as soon as possible. So that the appropriate specialty medical service cares for the medical problem of the patient.

Dr. Anton Titov, MD: This challenge of congestion and boarding in the Emergency Medicine department is explained partially by the way medical care functions in the United States. Unfortunately, a lot of patients in the US do not have health insurance.

People without health insurance have only one option to access medical care. It is done through the Emergency Medicine department of a hospital. They use Emergency Medicine physicians as primary care doctors.

Dr. Sam Shen, MD: There is a federal law in the United States called "EMTALA". This law demands that if Emergency Medicine departments receive money from the government, Emergency Departments must accept all patients who seek medical care.

All Emergency Departments have to provide a medical screening examination to everyone who seeks medical care. This is a great thing for the population in the US. It allows everyone to have access to a physician when they want or need to see a doctor.

Sometimes you walk into an Emergency Department, you will be seen by a licensed medical practitioner. A doctor will evaluate you for a life-threatening emergency. The positive side of this is good access to modern medicine for patients without regard to their financial situation.

The downside of that situation is that the EMTALA law requires hospitals to dedicate resources to see everyone who walks into the Emergency Department. This results in overcrowded Emergency Departments. As you stated, there are a lot of factors that influence overcrowding of Emergency Departments.

Lack of good access to appropriate primary care doctors is one of such reasons. Health insurance coverage and ability to access other types of medical care are also important reasons for overcrowding of Emergency Departments. It is a very complicated situation with many factors that influence it.

We certainly see the impact of these challenges when we provide medical care to a lot of patients. We have a limited capacity to provide medical care to them.

Emergency medicine: stay at hospital or go home? A video interview with a top expert in Emergency Medicine. How to improve patient experience and care quality?