Background: In the emergency department (ED), patients living in unsafe conditions in the community, who do not have a clinical reason to be admitted, present the physician with a dilemma: admit the patient to the hospital, exposing the patient to the hazards of hospitalization, or have them return to the hazards of their living situation. We developed a care pathway for urgently addressing the community needs of patients listed for inpatient admission, whose primary reason for admission is to avoid the hazards of unsafe conditions in the community, rather than clinical need.
Purpose: To create and implement a pathway in the emergency department, the urgent needs program, to urgently address the needs of patients being admitted for safety reasons rather than clinical need.
Description: The program was developed by the ED hospitalist program at an urban academic medical center. Criteria were developed for identifying patients, who might benefit from the urgent needs program. Criteria included: 1) listed for inpatient admission, 2) doesn’t meet the medical necessity criteria for inpatient services, and 3) has one of the following needs: patient or family requesting in home services, assisted living, or skilled nursing facility placement. Candidate patients are screened by the ED hospitalist, and if meeting criteria are added to a designated list in Epic. This triggers a team consultation including the ED hospitalist, a social worker, a case manager, and a physical therapist who meet with the patients and their families to develop a safe discharge plan from the ED.Since implementing the program in January 2020, 292 patients were screened, 88 of which were deemed to meet the inclusion criteria and received the intervention. The primary reason for presentation among the 88 patients enrolled fell into one of three categories: gait abnormality in 34 (39%), dementia with or without behavioral symptoms in 31 (35%) and seeking social services in 23 (26%). Of the 88 patients enrolled, 23 (26.1%) were discharged from the ED. Of the 23 patients discharged, 14 (60.9%) were transferred to a skilled nursing facility and 9 (39.1%) were discharged to home with new or increased services. Among the 55 patients who were admitted to the hospital despite the intervention, the median inpatient length of stay was 5.5 days. Barriers to discharge from the ED included: patient/ family needing time to choose a facility, family unreachable, no accepting nursing home due to case complexity, and unable to obtain insurance authorization in a timely matter.
Conclusions: We have successfully developed and implemented a pathway to identify and urgently address the safety needs of patients listed for admission for reasons other than an urgent clinical need. Admission to the hospital exposes patients to significant hazards including functional decline, delirium, nosocomial infections, pressure ulcers and venous thromboembolism. Faced with the choice of exposing patients to the hazards of an inpatient admission vs. the hazards of an unsafe situation at home, physicians in the ED have few good options. Our intervention resulted in a significant proportion of patients being discharged from the emergency department, despite being initially listed for inpatient admission.