Chapter 123. Co-Management of Patients in the Emergency Department

1. What strategies may improve emergency department (ED) throughput and minimize ED crowding?

2. How can hospitalists and Emergency Medicine (EM) physicians collaborate to improve the care of patients boarded in the ED?

3. How can hospitalists and EM physicians improve the quality and safety of hand-offs between their departments?

4. What basic principles underlie the operation of an observation unit?

Co-management of patients in the emergency department (ED) by Emergency Physicians and Hospital Medicine physicians has become necessary to alleviate ED crowding and optimize care of patients boarded in the ED while awaiting an inpatient bed. This chapter describes the challenge of ED crowding and how co-management strategies can improve patient flow from the ED into the hospital and improve the safety of patients who must be boarded. The chapter also examines two additional strategies for decreasing ED crowding: establishing a process for the triage of patients to appropriate services and locations within the hospital, and using ED based observation units.

Emergency Department Crowding

The Institute of Medicine in its 2006 report entitled Hospital-Based Emergency Care: At the Breaking Point1 concluded that EDs in the United States are in crisis, with hospital crowding being the single largest contributor to long wait times and adverse clinical outcomes. Investigators have found an association between ED crowding and a higher risk of adverse cardiovascular outcomes in patients with an initial diagnosis of chest pain. Others have found that, for patients with non-ST segment elevation myocardial infarction, long ED stays are associated with decreased adherence to clinical guidelines and an increased incidence of repeat myocardial infarction. An estimated 91% of the nation's EDs are overcrowded at any given time.

The causes of ED crowding are myriad and include increased utilization, demographic changes (most significantly the aging of the population), shortages of particular types of health care providers, and changing financial trends. Most significant amongst these were increased utilization and insufficient numbers of inpatient hospital beds. From 1996 to 2006 ED visits increased 32%, from 90.3 million to 119.2 million, equating to 325,000 visits per day. During that same time the number of ED visits per 100 persons rose 18%, from 34.2 to 40.5. In 2005 approximately one-fifth of the U.S. population had visited an ED within the previous 12 months. Ironically, the increase in ED utilization has been concurrent with a decrease in the total number of EDs. From 1996 to 2006 the number of EDs in the United States declined 4.6%, from 4019 to 3833 (Figure 123-1).

Although increased utilization and constrained ...