Moving Toward Solutions to Flow of Admitted and Transfer Patients

The role of emergency physicians and hospital leaders has dramatically escalated with the surges and medical system challenges produced by the COVID pandemic. The trends suggest emergency departments will see higher-acuity patients and more patients with complex medical needs.²

The emergency department is the portal into the hospital for critical patients who will either be admitted or transferred. Patients admitted from the emergency department account for about 67 percent of overall hospital admissions in addition to patients who will be transferred for admission to other hospitals. Any patient who requires boarding constitutes a challenge to ED operations, one that occurrs now for both admitted and transferred patients.

Because about a third of transfers relate to patients with mental health needs, the emergency department would benefit from community practices that feature the use of sites other than the emergency department for the management of persons with mental health and substance abuse issues. There are communities looking to implement mental health care sites and sobering centers as well as mechanisms that allow police and EMS to refer patients directly to those sites rather than to an emergency department.^3–6 The ability to process these individuals primarily to a site of quality mental health and substance abuse care is a positive and preserves the focus of ED care on medical and trauma patients.

Patient transfers are not infrequent and are resource-intensive for emergency physicians and nurses. Hospital and ED leaders must ensure that emergency physicians have easy-to-implement “patient transfer packs” that conform to EMTALA guidelines. Those processes allow the many steps to successful patient transfer to occur in an efficient matter, without wasting the time of the ED physician, nurse, or clerk trying to complete the process.

Many hospital systems have developed patient flow centers (or transfer centers), which had an important role even pre-pandemic in efficiently moving patients to the best site of care within the system. In response to pandemic surges, some states have developed dedicated hospital coordinating centers to improve the flow of patients outside of established hospital systems in an attempt to match patient needs with resources.^7,8 These centers certainly have a future role.

The rapid increase in ED patient transfers is a marker of the growing centralization of certain high-intensity clinical services and illustrates the need for a very effective system for organizing the movement of patients to those needed services. Perhaps it means that certain critical services need to be decentralized and delivered in more hospitals.

There is clearly a mismatch of services when millions of patients with mental health needs are processed in emergency departments and then packaged for transport to a definitive site of care.

Emergency physician leaders must appreciate the monumental challenges in acute care delivery that are occurring in the pandemic years and work with hospital leaders to serve a changing emergency population in the near future. Telehealth may have an important role in this regard.

The need to serve ED patients who must be transferred for definitive care is yet another important management priority

References

1. Cairns C, Kang K, Santo L. National Hospital Ambulatory Medical Care Survey: 2018 emergency department summary tables. CDC website. Accessed on Jan. 19, 2022.
2. Augustine JJ. Pre-COVID ED trends suggest more challenges lie ahead. ACEP Now. 2020;39(11):10.
3. Russell T, Doom A. Dallas works to avoid sending people in crisis to emergency rooms or jails. Pew website. Accessed on Jan. 19, 2022
4. Leseman M. Mental health first responders coming to Anchorage in 2021. Alaska’s News Source website. Accessed on Jan. 19, 2022.
5. Waters R. Enlisting mental health workers, not cops, in mobile crisis response. Health Aff (Millwood). 2021;40(6):864-869.
6. Whelan R. Americans seek urgent mental-health support as Covid-19 crisis ebbs. Wall Street Journal. June 27, 2021.
7. Galvagno Jr SM, Naumann A, Delbridge TR, et al. The role of a statewide critical care coordination center in the coronavirus disease 2019 pandemic—and beyond. Crit Care Explor. 2021;3(11):e0568.
8. Georgia Coordinating Center. Georgia Department of Public Health website. Accessed on Jan. 19, 2022.