“You need to go to the Emergency Department”: The Impact of Outpatient Referral on the ED

Greg Jasani 

January 8, 2018

Many healthcare policy experts have believed that expanding access to outpatient care would lower utilization of emergency departments (EDs).  Yet many outpatient providers often refer their patients to EDs when they believe them to be very sick and potentially in need of hospitalization, and when they don’t have the time or energy to handle their issue in an outpatient setting.  The ED provides a unique service for outpatient providers because, unlike most clinics, it can provide stabilizing and diagnostic interventions, bring in consultants, and even admit patients.

The impact of these referrals on ED volume and flow, however, is less well understood. A recent article in Annals of Emergency Medicine sought to determine whether referral by an outpatient provider was a predictor of illness severity and need for admission.  As the authors noted, if the majority of patients referred to the ED do not ultimately require admission then their diagnostic workup (i.e. blood tests, imaging) could potentially be done in a less acute, cheaper setting.  Conversely, if the majority of outpatient referrals do get admitted then ED providers should consider strategies to expedite these patients’ evaluation and admission.

The authors used data from the National Health Interview Survey, an annual survey administered by the CDC to assess healthcare utilization by Americans.  The survey asks respondents whether they visited an ED in the past 12 months and whether “their healthcare provider advised them to go”.  Of note, the survey does not ask respondents to specify what kind of outpatient provider (i.e. physician, NP, or even specialist) they saw.  From the data, 44,152,870 adults answered that they had visited an ED in the past year.  Of these, 10,913,271 were referred there by their outpatient provider.  The authors found that patients referred to the ED by an outpatient provider were more likely to require admission than those who were not (OR 1.74, 95% CI 1.56 to 1.94).  Even after controlling for other variables, outpatient referral remained an independent risk factor for hospital admission.

This paper shows that outpatient referrals are a significant source of ED volume as they accounted for approximately 25% of visits.  Perhaps more importantly, outpatient referral does appear to be correlated with illness severity as those referred to the ED by an outpatient provider were more likely to require admission compared to those who came in on their own.  This suggests that outpatient providers are assisting ED providers by triaging their own patients and only sending them to the ED when they cannot manage the situation themselves. However, many patients who are referred into the ED for care are ultimately discharged home.

The ED has become the easiest entry point for most unscheduled admissions to the hospital.  While many hope that expanded outpatient provider coverage will reduce ED use, it is important to remember that the ED is an invaluable tool for primary care providers as well.  The study found that on average, referred patients tend to be sicker. However, many patients who are referred into the ED for care are ultimately discharged home, meaning that considerable volume of ED patients could potentially have been treated in outpatient settings.  Going forward, both ED and outpatient providers have to work together to find ways to coordinate care so that when a patient goes from one setting to another, their full healthcare needs are met.

Greg Jasani is a fourth year medical student at the GW School of Medicine & Health Sciences