One in five admissions from an ED was considered preventable by either ED or general medicine physicians, although the two groups frequently disagreed on these conclusions, a recent study found.
The comparative cohort study looked at 401 patients admitted from an ED to a general medicine service over four weeks. The 82 physicians involved in the cases, in the ED or after admission, were asked to categorize the admissions as potentially preventable or not. ED physicians identified 22 admissions as potentially preventable (5.5%), while the medicine physicians identified 76 (19%) as such. In total, 90, or 22.2%, of the admissions were considered potentially preventable.
Study authors compared the potentially preventable admissions to the others and found no significant differences in patient or admission characteristics, such as patient age or time or day of ED presentation. They found shorter length of stay in the potentially preventable admissions (2.1 days vs. 3.6 days; P<0.001) but no other difference in patient outcomes. The study was published by the Journal of General Internal Medicine on Jan. 16.
Nineteen of the physicians were interviewed for the study and they described clinician, system, and patient factors affecting the decision to admit in these potentially preventable cases, including risk of deterioration at home, risk of hospitalization, cost to the patient, and presence of outpatient resources. They attributed the difference between the specialties' evaluations on which admissions were potentially preventable to differences in clinician training, risk assessment, and clinician understanding of outpatient access.
“When exploring reasons for differences in decisions, we found the difference to be most notable in cases where patients were considered to be in the ‘gray zone,’ when there was no clear decision for hospital admission,” the authors said. As a solution, they proposed more collaboration between ED and medicine physicians when deciding whether to admit such patients. “At this point, where patient care transitions from [emergency medicine] to [general medicine], [emergency medicine] physicians can best attest to risk of clinical decline at home, whereas [general medicine] physicians can best attest to optimal inpatient or outpatient management.”
This collaboration would be an alternative to previous efforts to reduce preventable admissions, which have handed ED patients off to medicine earlier in the care process. For patients in the “gray zone,” such collaboration “focusing on the risk of deterioration at home, the risk of hospitalization, the cost to the patient, and the presence of outpatient resources, may provide an avenue for reducing potentially preventable admissions and lowering healthcare expenditures,” the authors concluded.