Current research points to the fact that discharge from the ED is likely the biggest congestion point, and biggest factor contributing to ED overcrowding. Just like on the ED input side, there are many components of this problem that are outside the scope of what the ED can control; however, ED teams can work with others to help smooth the process of ED discharge. There are several ways that a patient can be discharged from the ED – they can be sent home, remain in a short-term observation unit, or be admitted to the hospital for further care.

Home

Patients who will be discharged to home may still need medical or social support at home – having case managers involved in patient care from earlier stages in the ED process can help expedite coordination of post-discharge needs. Ideally, having established relationships with outpatient care practices can help with coordinating care, so that elective and non-urgent workup can be deferred to the outpatient setting.¹

Observation

Observation units are an intermediate solution that are often near the ED, but geographically separated to allow for distinction of patient populations. Observation units have been shown to reduce hospital admissions, improve cost-effectiveness relative to inpatient care, and provide shorter length of stay than either inpatient admission or boarding within the ED.² Observation is sometimes used in cases where patients are medically stable, but have concerning findings that warrant more testing or specialty-level consultation that can be challenging to obtain in a timely way. One innovative solution is developing a rapid referral pathway for specialties that fall into this category – these specialties can reserve outpatient appointment slots specifically for time-sensitive follow up from ED referrals. In these cases, the ED is able to provide patients an appointment and specific instructions for follow-up, developing a robust follow-up system that ensures patients get connected to outpatient services.³

Inpatient

Evidence-based clinical support tools have been shown to reduce rates of inpatient admission from the ED, but inevitably some patients coming through the ED will need to be admitted for inpatient care. Having standardized and centralized operations for admission can help to make the process as streamlined as possible.³ One major contributor to ED overcrowding is boarding of inpatients in ED beds. Although this is fundamentally an issue of hospital capacity and hospital flow inefficiencies, boarding consumes valuable ED resources such as space, staff, and testing capacity, and limits the use of these resources for new ED patients.³ In the appropriate cohorts of patients, another option to consider is hospital-at-home care. Patients can receive their initial treatment in the ED, but then can go home with close monitoring through the use of continuous remote monitoring and telemedicine.³ 

References

1. Kenny JF, Chang BC, Hemmert KC. Factors Affecting Emergency Department Crowding. Emerg Med Clin North Am. 2020 Aug;38(3):573-587.

2. Joseph JW, White BA. Emergency Department Operations: An Overview. Emerg Med Clin North Am. 2020 Aug;38(3):549-562.

3. Kenny JF, Chang BC, Hemmert KC. Factors Affecting Emergency Department Crowding. Emerg Med Clin North Am. 2020 Aug;38(3):573-587.