Unless you work in a small hospital with critically low volume and a mostly empty ED, you are combatting crowding. ED crowding is at an all time high and the number of emergency departments in the US is shrinking as the number of ED visits increases. Though we once may have been able to accommodate lengthy evaluations and extensive imaging in the ED, no hospital can afford to do so today. One of the ways to reduce length of stay is to reframe the emergency department visit as a 4 hour (or less) evaluation period. From entrance to disposition, the patient needs to receive medications, interventions and have all imaging completed in under 4 hours. If there is further treatment required at that point, it is time to admit.
You can probably think of several reasons why an ED visit may run over 4 hours. If you work at an academic center, residents perform evaluations in a serial processing manner that is great for teaching, but not for patient flow. If you work at a trauma center, medical evaluations are frequently being paused as priority is given to trauma patients. If you work at a tertiary care center, transfers in are likely coming through the emergency department and receiving further diagnostics and treatment that are unnecessarily taking up critical ED time. Add to that the fact that the emergency department has become the staging ground for the battle against hospital crowding and we have the perfect storm. Lengthy evaluations in the ED are a vain attempt to prevent admissions which only further add to the already congested department.
If you are considering the option of holding someone in the department because they require more than 4 hours to accomplish a disposition goal, reconsider. There are times when we, emergency physicians, become our own worst enemy. We make concessions to help our admitting colleagues to our own detriment. Just hold that patient in the ED and transfuse 3 units of blood then send them home. Just sit on that patient in the ED and get a 6 hour repeat chest X-ray then send them home. Just give that patient a 4 hour potassium infusion and send them home. Just watch that patient for 6 hours or so and surely their mental status will get better as the drugs wear off. Just get another study, then another lab, then give another medication, then call someone else and tell them what we already know now, this patient should have been admitted hours ago.
I can hear the objections now: But there is no space anyway, but the patient just needs some blood and can go home, but they just need a repeat CT in a few hours, but but but… The truth is that there is a status for these patients and it is called “observation”. If your institution does not have an observation unit, be the spark to create one. Or if your institution has an ineffective observation unit, then make an argument for an ED run observation unit. So many of our patients qualify for a legitimate observation period that is necessary and reimbursable. You are doing the work already by holding the patient in the ED. A dedicated and properly staffed observation unit would actually bring additional revenue to the department. At a time when everyone is asking for money for special projects, the notion of an expansion that will increase revenue seems unheard of, but it is true. Walk through your ED and ask: what is the percent of patients in our department who spend more than 4 hours in the ED? If your radiology and lab goals are being met, then you likely have patients holding in the ED who qualify for observation.
The next time you are faced with the choice to admit someone or hold them in the ED for treatment, call for the observation admission. There are enough barriers to ED patient flow without us adding to the list.