It’s 11 PM, and the ED is packed. People have been waiting hours to be seen, and tempers are flaring. Patients deemed ill enough for admission lie in gurneys in the halls, waiting for hospital beds to become available. But many people in the ED are hardly emergent cases: One man wants a medication refill, one woman has joint pain in her knees, and a teenager is complaining his tooth hurts. The ED is at capacity, and the hospital has no choice but to divert emergency medical services to other facilities.

This scenario occurs every day in EDs across the country. EDs are filled to capacity, but many people seeking care don’t really need ED services. What is the solution?

Reports show that 40% of all admissions to the hospital come through the ED.¹ This means that ED nurses are typically the first hospital health care workers to come in contact with ED patients. This gives nurses the responsibility of determining the reason for patients’ visits and implementing efficient and cost-effective measures for care. This affects nursing practice by offering new challenges and possibilities for care.

ED overcrowding first made news in the early 1990s. Over the past few years, the problem has escalated and has captured the attention of the public and policy makers.^2-4 During the 1990s, the U.S. lost more than 100,000 hospital beds, almost 8,000 of those being ICU beds.⁵ ED visits have continued to increase, growing from 90 million in 1992 to 114 million in 2003, a 27% increase. At the same time, there has been a 15% decrease in the number of EDs throughout the country.^5-8

ED economics

If demand is increasing, why is capacity decreasing? The answer is one of simple economics. On average, the ED will collect only 30% to 50% of the charges for emergency services.⁹ In some areas of the country, as much as 30% of hospital ED volume consists of self-pay, uninsured patients.¹⁰ Almost 46 million Americans are without health insurance.¹¹ The collection rate for this uninsured group is not very high. Additionally, ever-decreasing reimbursement by Medicare and Medicaid creates a significant financial strain on hospitals. Often the reimbursements do not even cover the total costs of the ED visit.³

The federal government requires that all patients presenting to an ED for care receive a medical screening exam to determine whether a true emergency exists.¹² While the government has mandated that EDs must provide screening and, in some cases, stabilizing care, it has not provided funds to hospitals to subsidize these services.

So how do hospitals make ED visits cost-effective? The burden usually shifts to managed care companies. That happens because self-pay patients usually can’t pay, and Medicare and Medicaid reimbursement generally doesn’t cover costs. As a result, hospitals charge managed care companies as much as possible to cover the overall cost of health care. Managed care companies then cover the cost by either limiting patient services or raising premiums.

Cost of ED care

Investigators have charged that ED care is much more expensive than care at a physician’s office or in a clinic. One study found that a nonurgent visit to the ED costs three times as much as a visit to a physician’s office.¹³ Another report found that the costs were 80% higher in the ED than other settings.¹⁴ However, this can be misleading. If you look at only total costs, it’s more expensive to see a patient in the ED. But if you look at only the marginal cost, or what it costs to see one additional patient, the picture is different.¹³ The ED is already open and staffed to take care of all emergencies. Every additional patient lowers the fixed costs of operating the ED, and generally one extra patient does not raise staffing levels. Physician’s offices are not usually open during the night or on weekends. The cost to open them and staff them for patient care would be very high.

Nonurgent care

One of the biggest issues facing EDs is the large number of nonurgent patients seeking care. Investigations have shown that from 9% to 55% of all ED visits are nonurgent.^5,15-18 One study even revealed that as many as 85% of ambulance patients can be classified as nonurgent.¹⁵ (The large variations in these findings are due to differences in how researchers define “nonurgent.”)

Many people feel that this is an indigent health problem, with people who lack health insurance using the ED as their primary care source. But researchers have found that lower socioeconomic groups don’t have a higher ratio of nonemergent to emergent visits than high socioeconomic groups do.¹⁵ Remarkably, the privately insured population is the largest group of people seen in EDs.³ In the nonurgent population, ensured patients are actually the majority.^15,16 Many of these patients say that they called their primary care physician or provider, who advised them to go to the ED.^2,4

Access to primary care

Several explanations have been given for the large number of insured nonurgent patients in the ED. The majority are related to access to primary care, which appears to be a major issue regardless of the patient’s socioeconomic status. We are a society that likes everything right now. Many people don’t want to wait to see a primary care provider if they cannot get a same-day appointment.¹⁵ Some think that the ED can administer better care for their problems or that their problem is too urgent to be handled in a medical office or clinic.¹⁶

As many as a third of nonurgent patients cite difficulties in accessing primary care as the reason for coming to the ED.^8,19,20 Medicaid patients have been shown to have limited access to outpatient services other than the ED.¹⁹ For these patients, the ED is their only option for care.²

During the 1990s, many urgent care centers opened in response to ED overcrowding. But this has not fixed the problem: Urgent care centers are limited in number, have limited hours of operation, a finite capacity, and often ask for payment upon service.¹⁷

EDs have searched for ways to shift the nonurgent patient population out of the ED and into primary care. Some of the methods include —

• Requiring that primary care providers “authorize” patients to seek care in the ED.
• Encouraging primary care providers to educate patients about the appropriate use of emergency services.
• Referring nonurgent patients from the ED to primary care.

Triage

Focusing on the third option: What is the best way of referring nonurgent patients from the ED to primary care? The first step is establishing a triage system.

If staffed exam rooms were available for every patient who arrived in the ED, including nonurgent patients, EDs would not need a triage process. As the ED fills to maximum capacity, forcing patients to wait for evaluation and treatment, nurses must prioritize patients.

Several types of triage exist. Some facilities use two levels of acuity, some three, and others five. In facilities that use only two levels of acuity, patients are classified as emergent or nonemergent. This does little to prioritize the patients. The vast majority of patients do not fit into the emergent category. With so many patients classified as nonemergent, the model provides little guidance for which patient should be seen next.

The three-level triage system was popular in the U.S. for many years. This model classifies patients as emergent, urgent, and nonurgent. Traditionally, the emergent category consists of patients who have the clear potential to deteriorate into life-or-limb situations. The urgent category generally includes patients who have conditions that require attention within several hours. The nonurgent category consists of patients with stable conditions who can wait for evaluation and treatment.

Both the Emergency Nurses Association and the American College of Emergency Physicians support a five-level triage system. This system is much more precise in the classification of patients and is quickly gaining acceptance throughout the U.S. and internationally. The bottom two levels of this system, four and five, allow better prioritization of nonurgent patients, determining who can wait several hours for evaluation and treatment and who can be referred from the ED to primary care.

Other models of triage address the depth of triage assessment. In a comprehensive triage model, the triage nurse obtains vital signs, a focused history, and perhaps medication and allergy history and performs a brief focused physical examination. On the other end of the spectrum is the “quick-look” triage. The triage nurse visualizes the patient, asking a few questions, gathering only enough information to form an educated opinion of the severity of the patient’s condition. These models are two ends of a continuum, with many points in between. Although most EDs set their point on this continuum through policies or standard operating procedures, the best method may be to move along this continuum as time and workload permit. If there are few patients to triage, a more comprehensive model may provide more benefit. However, if there are many patients to triage with limited resources, a quick-look triage may allow nurses to identify more emergent and urgent patients in a shorter span of time, which is, after all, the primary purpose of triage.

Screening of nonurgent patients

Certain types of patients can be safely referred out of the ED if they have access to primary care in the community.⁸ These include patients with the most common nonurgent complaints: extremity/joint pain or trauma, back pain, tooth pain, and medication refills.^8,19,21

The referral process is fairly simple and seems to be fairly standardized between hospitals. The patient presents to the ED requesting care. An experienced nurse triages the patient. If the patient is emergent or urgent, he or she will be placed in the main ED for evaluation and treatment. Patients triaged as “nonurgent” will be given a medical screening exam. Requirements on who can legally perform the medical screening exam vary from state to state. In some states, a specially trained triage nurse can perform a medical screening exam.^8,17,19 In other states, a physician, physician’s assistant, or a nurse practitioner performs the exam.¹³

If the medical screening exam reveals that the patient doesn’t have an emergency medical condition, he or she is a candidate for referral from the ED. Pediatric, psychiatric, and very elderly patients usually are not referred because of higher risks they present.

In some hospitals, a patient who doesn’t have an emergency medical condition is sent to an information desk for help in making a primary care appointment or to obtain a list of resources at which to seek primary care.^8,19 These patients generally do not incur charges for the medical screening exam.

At some hospitals, patients are referred to a financial counselor if a medical screening exam indicates that they don’t have an emergency medical condition. The counselor gives the patient the choice of providing a method of payment for the visit or seeking primary care outside of the ED.¹² Although allowing patients to stay in the ED if they can pay will not help reduce overcrowding, hospitals may have a financial incentive to do so. As discussed, the marginal cost to care for one more patient in the ED is very low. Therefore, any payment may result in a profit.

Clinicians providing the triage assessment and the medical screening exam should not be aware of the patient’s payer status.⁸ EDs are required to care for all patients with an “emergency” condition regardless of their ability to pay. Once the medical screening exam is complete and no evidence exists of an emergency medical condition, the Emergency Medical Treatment and Labor Act (EMTALA) does not obligate the ED to treat the patient.¹² The patient can then be referred to a financial counselor. Any discussion of finances before the medical screening exam may lead the patient to believe that the decision to refer was based on financial rather than medical factors.

Many EDs have conducted follow-up phone calls to determine whether referred patients had been able to access care outside of the ED.^8,10,17,19 The key to success is having a community infrastructure that can support the referrals for all patients. Even in communities with adequate numbers of primary care physicians, urgent care clinics, and community health clinics, if care for the indigent population cannot be met, the ED will continue to serve as the safety net.²

Outcomes

A major obstacle in assessing outcomes of ED referrals is the difficulty in contacting patients. In three separate studies, EDs attempted to call patients 48 to 72 hours after referral. In 25% to 40% of cases, the patient could not be reached due to either an incorrect phone number or no answer after several attempts to call.^8,10,17 Of the patients contacted, 22% to 40% completed their follow-up appointments.^8,10,17,19 Forty percent to 59% said their problem had been resolved, negating the need for further care.^8,10

Up to 26% of these patients sought care in another ED.^8,17 At one hospital, about 2% of the ED patients returned to complain about an inability to access care outside of the ED.¹⁷ In two studies, the investigators showed no statistical differences in ED use after implementation of the referral process.^10,19 However, a few hospitals have shown a slight decrease in ED volume. One hospital in the greater Houston area has seen a 2% reduction in ED volumes, which correlates to the average percentage of patients referred from the system’s EDs. The volume reductions would have been greater had it not been for hurricanes Katrina and Rita, which brought to Houston many people who used the ED because they didn’t have established primary care in the area.²²

No study has revealed any serious patient safety issues. About 1% of the patients referred out of EDs were found to need hospital admission.¹⁷ Additionally, one study showed that 1% of patients returned to the ED for care within 48 hours of being referred.¹⁸

Although it would appear that this process does little to reduce ED overcrowding, it may have the significant benefit of strengthening the community health infrastructure. A hospital in California that referred nonemergent ED patients to primary care experienced an annual reduction in the number of nonurgent patients reporting to the ED. The study investigators correlated this result with improved access to primary care that occurred at the same time.¹⁷

The second benefit of a referral process may be more timely care for patients in the ED (i.e., faster ED throughput), at least in hospitals in which a physician, physician’s assistant, or nurse practitioner performs the medical screening exam. With a referral process in place, the medical screening exam tends to be conducted earlier. (The faster the patient is screened, the faster referral can take place.) This gives the patient quicker access to the medical provider, and allows the medical screener to order testing and initiate protocols. If the patient decides to stay for nonurgent treatment, medical tests can be performed so the results are awaiting the physician when the patient eventually gets placed in the main ED. This may have a greater effect on ED overcrowding than simply trying to move nonurgent patients to other venues of care.

Solutions

The primary goal of upfront medical screening is to reduce ED overcrowding, but the literature does not indicate that this goal is being achieved. Therefore, nursing is left with two major implications. The first is to find another method to reduce ED overcrowding. The second is to develop an efficient and cost-effective method for dealing with nonurgent patients.

Barriers to accessing primary care must be removed. When patients have no insurance and limited financial resources, they find it too difficult to access primary care.⁸ Even when patients can afford primary care, the issue of patients’ perceived urgency remains. In one analysis, it took an average of eight days to get an appointment with primary care.⁸ Some patients will not wait this long and instead return to the original ED or to another ED. ED nurses, physicians, and administrators must take a lead role in developing a community health infrastructure that can connect patients with timely and cost-effective primary care. Only when the patient’s needs are satisfactorily met will ED utilization change.²³

Some would say that EDs should embrace nonurgent patients and seek to treat them, thus expanding ED capacity to meet the need of patients. The literature shows that the majority of the nonurgent patients in the ED are actually insured.^15,16 These patients spend less time in the ED and use fewer resources than emergent or urgent patients, and have lower admission rates.^4,16,21 The acuity of this patient group makes them well suited for care by a physician’s assistant or nurse practitioner.¹⁶ All of these factors, coupled with the low marginal cost of ED care, make the ED a financially appropriate venue of care, especially after regular physician office hours and on weekends.^4,9,16 Cost savings are the key to profitability in health care today.²

ED volume has grown steadily over the past decade. At the same time, there has been a reduction in the number of hospitals providing emergency services and in the number of inpatient beds. This has resulted in overcrowding, long ED visits, admitted patients being boarded in the ED, and reduced patient, physician, and staff satisfaction.

In most businesses, if volume increases, operations expand to meet the demand. However, because of an increasing number of uninsured patients, decreasing government reimbursement, and escalating health care costs, some hospitals are reluctant to increase ED capacity. Reducing the number of nonurgent patients seen in the ED through the referral process will not have any substantial effect on society’s health care costs. In fact, in many cases the ED may be more cost-effective overall, especially if timely and appropriate ED treatment for nonurgent conditions prevents more costly conditions, such as pneumonia or sepsis.

The true key to reducing ED overcrowding is providing affordable, accessible, high-quality primary care in the community. These services must be in place for the referral of nonurgent patients to be effective. Otherwise, patients will continue to use the ED as their primary source of care.