As the nexus between the outpatient and inpatient care delivery systems, the Emergency Department is increasingly the gatekeeper of inpatient admissions.

Although the complexity of ambulatory care patients is increasing, the result of economic pressures on primary care physicians is a schedule that causes the older and sicker patients to receive only  the same amount of physician time as the younger, healthier patients. As ambulatory care providers have less time to thoroughly assess the patient and arrange for direct admission, patients are increasingly sent to the ED.  The result: now greater than half of all inpatient hospitalizations are originating in the ED.

Given this dynamic, it is not surprising that the number of ED visits has been increasing significantly.  Over a recent twelve year period, visits have increased by 35%-- from 94.8 million in 1998 to 127.2 million in 2010.

But is this a bad trend? While the entirety of emergency care accounts for less than 3% of healthcare spending, inpatient hospitalization accounts for approximately a third of healthcare dollars.

In fact, the ED is in the unique position of being able to offer intensive inpatient resources to ambulatory patients without requiring hospital admission – essentially providing the needed inpatient resources without requiring inpatient admissions.  Using the equipment of the acute care hospital, the ED can provide services such as advanced imaging, minor surgery, intensive treatment, procedural sedation, and respiratory support. 

Access to these allows the Emergency Department not only to diagnose and facilitate admission for patients needing inpatient care, but also to diagnose and fully treat ambulatory patients who are appropriate for discharge and continued outpatient management. For example, a patient with a hip dislocation does not need to be admitted to the hospital and go to the operating room for sedation.  Rather, the emergency physician typically provides procedural sedation and closed reduction of the hip, followed by discharge and outpatient management.

The ED, in its expanding role as the nexus between inpatient and outpatient care, will be a key focal point for developing ways to deliver needed inpatient resources without inpatient admissions. But to keep up, the ED will need to expand its ability to deliver inpatient treatments to patients that can allow them to be discharged back to their primary medical doctors.