Services outside the emergency department often report that additional testing is faster in the emergency department. However, Penn State Health Milton S. Hershey Medical Center’s imaging department studied the time it takes to obtain imaging studies and found studies were obtained only 15 minutes faster in the emergency department. This finding argues against holding patients in the emergency department for additional diagnostics.

Possible Solutions

To improve delays related to contested admissions in your facility, considering employing the following tactics:

Admission agreements: The first set of admission agreements we know of were the Stanford Admission Rules drafted in 2004. They were presented in a matrix and provide basic agreements for admissions to different services. Admission agreements can take months to years to draft and still do not anticipate every possible scenario. I recently witnessed a case of a patient on warfarin with a head injury who was neurologically intact. The ED workup revealed a ST-elevation myocardial infarction and an ischemic foot. More than four hours were spent determining the admitting service. Areas of contention included orthopedics and medicine, neurology, and neurosurgery.

Bridging orders: Bridging orders should be short-term and timed-out, allowing patients to be admitted from the emergency department to the floor while the admitting service finishes clinical or surgical work.² These orders have always been endorsed by the Institute for Healthcare Improvement (IHI). They are useful in smaller facilities but can have a place in busier facilities and academia, too.

No-refusal policies: Many organizations have adopted no-refusal policies, which may be applied on the physician side and the nursing side. Such policies mean when a bed is available and a service identified for admission, there is no answer but yes. The emergency department is empowered to determine the admitting service. This model has been applied at Brown University, Washington University, Brigham and Women’s Hospital, and Carolinas Medical Center. Some sites have taken an additional step of allowing a service to refuse a patient as long as it then finds an alternative arrangement for the patient.

Shared metrics: According to Edward Jauch, MD, MS, professor and director of the division of emergency medicine at the Medical University of South Carolina, his institution has implemented shared metrics for admitted patients for the emergency department and admitting services. Shared metrics include a goal of one hour for admission to the surgical ICU. This policy originated in the C-suite and puts income at risk for not meeting shared metrics, including length of stay. It also requires professionalism and courtesy. When this policy went live, it produced a profound effect on patient flow.