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Freestanding ERs May Have Low Hospital Admission Rates

By Christopher Cheney  
   June 20, 2018

Researchers find that patients at a hospital-based emergency department were 20% more likely to be admitted compared to patients at freestanding emergency departments.

Contrary to some critics, recent research shows that freestanding emergency departments may not admit patients for inpatient care at higher rates than hospital-based emergency departments.

The research, which was published this month in the American Journal of Emergency Medicine, was conducted at Cleveland Clinic's tertiary hospital-based emergency department (HBED) and two of the health system's freestanding emergency departments (FSEDs).

"These results show that a patient who presented to our HBED trended towards a 20% higher likelihood of admission than if a similar patient presented to our hospital-based FSED," the researchers wrote.

While the 20% variation was not considered statistically significant, it does represent a trend, according to the researchers.

There are two kinds of freestanding emergency departments:

  • Hospitals and health systems operate hospital-based FSEDs, which must be state-licensed and adherent to Medicare Conditions of Participation.
  • Non-hospital, for-profit organizations operate independent freestanding emergency departments, which are not recognized as emergency departments by the Centers for Medicare & Medicaid Services.

Data for the 3,230-patient study was collected from 2015 health system statistics. The researchers focused on admission rates for four health conditions: chest pain, chronic obstructive pulmonary disease, asthma, and congestive heart failure.

The patients were closely split in their emergency department usage, with 53% using the HBED and 47% using the two FSEDs.

The researchers found that more of the HBED patients were admitted than the FSED patients:

  • Of the 1,708 patients who used the HBED, 49% (842) were admitted
  • Of the 1,522 patients who used the FSEDs, 42% (645) were admitted

In addition to the presenting condition, the researchers note several factors can influence an emergency medicine physician's decision to admit a patient. Those factors include convenience, transportation costs, availability of outpatient follow-up, social supports, and the need to 'turn' a bed to reduce waiting room time.

The researchers speculate there are at least two possible explanations for the observed higher rate of admissions from their HBED compared to the FSEDs.

1. Facility factor  

An earlier study demonstrated that facility-related factors drive higher rates of admission from emergency departments.

"Having higher hospital occupancy rates, higher number of inpatient beds, being in an urban location, and having a level 1 or 2 trauma center were all associated with higher ED admission rates," the Cleveland Clinic researchers wrote.

For example, chest pain patients evaluated in an HBED could receive faster additional care as inpatients rather than waiting for a second set of lab work in the ED and an outpatient cardiac stress test.

2. 'Turn' temptation

HBED physicians may be under pressure to ease waiting room congestion and 'turn' beds.

"In a busy HBED the physician that does not 'turn' beds quickly can pose a risk to quality and patient satisfaction for the entire hospital system," the researchers wrote.

They say FSED physicians appear to have less bed-turning pressure.

"FSEDs tend to have lower volumes and shorter wait times. The pressure to 'turn' patients quickly is not as profound allowing the physician time to arrange follow-up and perform longer work ups."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Hospital-based ED had higher admission likelihood than freestanding EDs

Study focused on patients with chest pain, COPD, asthma, and CHF

Explanations for study finding include pressure to 'turn' beds

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