Hospital Emergency Departments

Utilization and Resource Deployment in the Hospital as a Function of the Type of Referral

Background: Inpatient admission rates and the resources required upon admission to the hospital were studied as a function of the type of referral to the emergency department (ED) of a university hospital.

Methods: We retrospectively analyzed data concerning patients who were treated in the ED of the University of Leipzig Medical Center in 2019. The following data were recorded: process data, type of referral, hospital admission vs. discharge from the ED, and leading symptom according to classification as „trauma“ or „non-trauma.“ For all admitted patients, the Patient Clinical Complexity Level (PCCL), length of hospital stay, and intensive care (yes/no) with or without ventilation were recorded.

Results: Data on 34 178 patients (50.9 ± 22.2 years, 53.8% male) were analyzed; 28.8% of patients were referred because of „trauma,” and the remaining 71.2% for “non trauma”. The most common sources of referral were the rescue and emergency medical services (47.7%) and the patients themselves (self-referrals, 44.7%); 7.6% of the patients were referred by a resident doctor or general practitioner (physician). 62.6% were discharged from the ED after diagnosis and treatment, while 37.4% were admitted to the hospital. In comparison with self-referred patients as a baseline, the likelihood of inpatient admission was higher when the patient was referred by a physician (adjusted odds ratio [OR] 2.2), by the emergency rescue service without an emergency physician (OR 3.4), by an emergency physician (OR 9.3), or by the helicopter rescue service (OR 44.1). 49.1% of patients with trauma referred themselves to the ER, and 36% were referred by the emergency rescue service. Older and male patients were more likely to be admitted to the hospital, especially for non-trauma. 30.4% of the admitted patients required intensive care, and 35.5% of the patients in intensive care required ventilation.

Conclusion: Whether a patient is admitted to the hospital depends on the source of the referral and the leading symptom on arrival in the ED. One in every six self-referred patients is admitted to the hospital, particularly when the reason for presenting to the ER is non-traumatic and some of them go on to receive intensive care. The high percentage (around 95%) of self-referred trauma patients that are discharged from the ED presumably indicates that they were referred mainly for the exclusion of dangerous conditions, and/or that appropriate care options are lacking in the community setting.

By providing care to about 10.5 million patients in Germany each year, hospital emergency departments (EDs) carry the larger share of the 19 million acute and emergency patients treated in combination with the emergency medical service (Ärztlicher Notdienst) on an outpatient basis. Together with the 8.7 million patients remaining in hospital after diagnosis and treatment, the main burden of acute and emergency care in Germany continues to borne by the EDs (e1).

The 2018 expert report of the Advisory Council describes deficiencies in the organization, provision and coordination between the outpatient sector and inpatient emergency care. It calls for a modification of the care structures and better ways to direct pedestrian patients in particular. (e2). It is not only the tabloid press that conveys the impression that the high case numbers in the EDs with “overcrowded outpatient departments, irritated patients and stressed-out staff” can essentially be explained by a large number of patients treated there unnecessarily, because they just as well could be treated in the community setting. In addition, it is argued that the diagnostic and treatment effort and thus the costs are too high and many inpatient admissions are not necessary (1, e3, e4, e5, e6).

The discussion surrounding the German Healthcare Advancement Act (GVWG, Gesundheitsversorgungsweiterentwicklungsgesetz), which takes up directing patients to appropriate care settings, reinforces this impression. The results of current deliberations of the Federal Joint Committee (G-BA, Gemeinsamer Bundesausschuss) on the initial assessment and directing of patients remain to be seen (e7, e8).

Under discussion are various proposals, such as, for example, an obligation for pedestrian patients to primarily visit a central point of contact in the community setting as the only access to emergency care, and only present to a hospital after such an initial assessment was performed. The self-initiated presentation of pedestrian patients to the ED should be reduced to a minimum or no longer be allowed (1). However, other authors describe safely directing patients to the appropriate level of care, while taking urgency into account, as a challenging task that is not adequately achievable with the currently proposed initial assessment systems (2). It should be noted, though, that there is a higher pretest probability of a serious medical problem when patients present to the ED compared to when they present to a community-based service (3, 4, 5, 6). Thus, referrals from other medical care settings would be expected to result in a higher rate of hospital admissions than would self-initiated presentations.

Thus, the aim of this study was to assess inpatient admission rates as a function of the source of the referral and for self-referred ED patients, respectively, and to evaluate the resources required for providing care for patients admitted to the hospital.

Methods

In a retrospective study, we further analyzed anonymized data of all patients who were treated in the ED of the University of Leipzig Medical Center (UKL) between 1 January and 31 December 2019. These data were analyzed as part of the UKL ED’s reporting and quality management activities; the data protection supervisor was consulted for advice. The requirements of the General Data Protection Regulation (GDPR, Datenschutz-Grundverordnung) were taken into account (eBox 1).

eBox 1

University of Leipzig Medical Center (UKL): an emergency care hospital in Leipzig, Germany

Besides process data, the following parameters were recorded:

• Type of referral (helicopter rescue service, emergency physician, emergency rescue service without an emergency physician, resident doctor or general practitioner [physician], and self-referrals)
• Type of case (admitted to the hospital vs. discharged from the ED after diagnosis and treatment)
• Leading symptom.

Patients were classified according the leading symptom on arrival in the ED in the two groups “trauma“ and “non-trauma“ in order to study potential differences with regard to the source of the referral and the admission behavior (eBox 2).

eBox 2

Leading symptoms non-trauma/trauma

With regard to the referral type, admission to hospital after ED treatment and for all admitted patients additionally the Patient Clinical Complexity Level (PCCL), length of hospital stay, intensive care, and duration of ventilation were recorded. (eBox 3).

eBox 3

Additional information on the statistical analysis

Results

During the study period, 35 142 patient contacts were documented and after exclusion of 962 patients secondarily referred to ED and two patients with missing data sets, 34 178 patient contacts (age: 50.9 ± 22.2 years, m/f: 53.8%/46.2%) were included for further analysis (eBox 4).

eBox 4

Patient age with regard to source of the referral

Type of referral

The most common sources of referral were the rescue and emergency medical services with 47.7% (emergency rescue service 35.6 %, emergency physician 11.4 %, helicopter rescue service 0.7 %), followed by self-referrals (44.7%). Community-based physicians referred 7.6% of patients, of these 60.9 % between 6:00 am and 2:00 pm (eTabelle).

eTable

Patient presentation by time of the day and type of referral

Case type

After diagnosis and treatment in the ED, 62.6% of patients were discharged from the ED immediately and 37.4% were admitted to the hospital for further treatment. The inpatient admission rate is with 51.7% to 86.9% higher among patients referred by the emergency rescue service compared to referrals by a physician and self-referrals (38.4% and 16.0%, respectively).

Among the inpatient cases, referrals by the emergency rescue service made up the highest proportion (63.3%) (Table 1, Figure, eBox 5).

Figure

Type of referral and case type, Emergency Department of the UKL 2019

Table 1

Type of referral and case type in patients with trauma and non-trauma

eBox 5

Main diagnosis groups in hospitalized patients

Leading symptom: trauma versus non-trauma

9839 (28.8%) ED patients had a leading symptom of the “trauma“ group and 24 339 (71.2%) one of the “non-trauma“ group.

The majority of patients with trauma referred themselves to the ER (49.1%) or were referred by the emergency rescue service (36.0%). Patients referred by the rescue and emergency medical services had the highest admission rates, while physician referrals and self-referrals had the lowest (Table 1).

Hospital admission by type of referral and leading symptom

Older and male patients were at a higher risk of being admitted to the hospital, as did patients with a leading symptom of the “non-trauma” group compared to patients with a leading symptom of the “trauma” group. Compared to self-referred patients, patients of all other types of referral were at a significantly increased risk of being admitted to the hospital. Among these, patients referred by helicopter rescue service had a 44-fold increase in risk of hospital admission and were thus most at risk (Table 1, Table 2).

Table 2

Inpatient admission as a function of leading symptom and type of referral

Patient Clinical Complexity Level, length of hospital stay, intensive care, and duration of ventilation

Among the patients admitted to the hospital from the ED, the PCCL was 1.5 ± 1.6 and the mean length of hospital stay was 9.1 ± 11.2 days. 30.4% of the inpatients required intensive care, of which 35.5% were ventilated, and the duration of ventilation was 11.9 ± 82.2 hours (Table 3, Table 4).

Table 3

Patient Clinical Complexity Level and length of hospital stay as a function of the type of referral

Table 4

Intensive care and ventilation in admitted patients of the emergency department

There was no statistically significant difference in the PCCL of inpatients referred by a physician and self-referred inpatients. In contrast, inpatients referred by helicopter rescue service were at greater risk for a higher PCCL compared to self-referred patients, as were emergency rescue service- and emergency physician-referred patients.

The type of referral also influenced the length of hospital stay. The length of stay was significantly longer among helicopter rescue service- and physician-referred patients compared to self-referred patients (Table 3).

Patients referred by the rescue and emergency medical services were at an increased risk of receiving intensive care compared to self-referred patients (18-fold among patients referred by helicopter rescue service).

Among ventilated patients, the duration of ventilation also depended on the referrer. It was longer in patients referred by helicopter rescue service, emergency physician and emergency rescue service compared to self-referrals (Table 4).

Discussion

Our study at a large ED of a university hospital shows that hospital admissions for inpatient medical support depend on the referring physician and the leading symptom on admission. Self-referrals are also justified since one in six self-referred patients—especially with leading symptoms from the non-trauma group—require further inpatient treatment. In contrast, numerous trauma patients, including patients referred by community-based physicians, can be discharged after diagnosis and treatment in the ED.

The proportion of 48% of patients referred by emergency rescue or emergency physician services appears to be higher in the UKL ED and that of self-referrals, at 45%, lower than those in other EDs of university hospitals (e.g. 31% and 68%, respectively, in the Düsseldorf University Hospital). Focusing on the field of general medicine, 80% self-referrals are reported for 2,100 pre-selected patients (e10). Data of the AKTIN project highlight a correlation with the level of care: Comprehensive emergency care hospitals report about 35% referrals by rescue and emergency physician services and, at 47%, a proportion of self-referred patients comparable to that seen in the UKL ED (e11).

In the UKL ED, the hospital admission rate is at 37% and highest among helicopter rescue service- and emergency physician-referred patients, but it is also significantly higher among referrals by the emergency rescue service without an emergency physician compared to referrals by community-based physicians. These data underscore the findings of previous studies which indicate that in the out-of-hospital setting even emergency physicians are not always able to correctly evaluate the indication for further inpatient treatment (8).

Of significance, however, is the proportion of 16% self-referred patients who are admitted to the hospital, i.e., one in six patients presenting to the ED on their own initiative. Other hospitals report admission rates of 20% to 60%, depending on patient spectrum (e9). An analysis of 525 000 treatment cases of emergency departments in Munich showed that about 60% to 85% of patients are discharged from the ED after diagnosis and treatment (9).

In this paper, the mean length of hospital stay among the patients admitted by the ED was, at 9.1 days, above the UKL’s overall length of stay (2019: 6.6 days) and also above the length of stay among German hospitals overall (7.2 days) (e12). Prolonged hospital stays for emergency patients can be explained by the greater diagnostic and therapeutic effort required when the leading symptom is inconclusive and the illness or injury is severe. Differences in treatment processes, however, are also conceivable: A study conducted at a hospital with two sites in Berlin found an ICU admission rate almost twice as high at one site; surprisingly, however, the length of hospital stay of five days at both sites was comparable and significantly below the national average (10).

At the University of Leipzig Medical Center, almost every third patient admitted to the hospital or every eighth patient referred to the UKL ED requires intensive care. PCCL, length of hospital stay, admission to the intensive care unit and the need for ventilation also depend significantly on the type of referral. The large proportion of patients requiring intensive care is comparable with the percentages reported from other comprehensive emergency care centers. It underscores the high severity of illness or injury among the patients treated in the ED of the UKL and the resulting need for adequate intensive care capabilities in terms of space, equipment and staff (11, 12, 13, e11).

The impression conveyed not only in the lay press but also in the specialized healthcare press that self-referrers present to EDs in an unwarranted manner is not supported by the data of our study (1, e1, e2, e3, e4, e5): 16% of these patients without prior physician contact require inpatient care and, of these, 13.1% require intensive care. Our data are comparable with the results of other emergency departments. For example, a study on 421 027 patients presenting self-referred at emergency departments in Munich showed that in 19% of cases inpatient admission to a ward and in 7% admission to an intensive care/observation unit occurred (9).

These results underscore that the call to turn away patients who present to EDs on their own initiative is neither medically nor ethically justifiable (e4, e13). Many severely ill patients present with unspecific leading symptoms and the indication for further inpatient care can only be established after initial medical assessment, diagnosis and treatment in the ED. (2, 14). Presenting information created retrospectively based on billing data, which often gives the impression that the patient treated in the outpatient department could have been treated elsewhere from the start, distorts reality. (e1). We ultimately need large studies to answer the question of which care setting is most appropriate for the various patients and sources of the referral and also—as for example in the AKTIN project—registry data regularly collected immediately during care delivery (15, e11).

In the community/statutory health insurance physician setting, it often seems impossible to perform an adequate differential diagnostic work-up, even during practice opening hours: In our study, over 60% of the referrals from community-based physicians/general practitioners were made during the morning hours. More than 60% of the patients referred by community-based physicians were discharged from the ED after treatment. The fact that a definite diagnosis and assessment of the need for inpatient admission cannot reliably be achieved in the community setting is also demonstrated by data from earlier studies, finding less than 50% agreement between the referral diagnosis and the ED diagnosis (16). These results are also confirmed by the PiNo study evaluating five emergency departments in northern Germany. The study found that self-referred patients with chronic conditions assessed as “not immediately“ or “not very urgent“ did not present unnecessarily at the emergency department (17).

The proportion of patients classified as “trauma“ is also subject to site- and structure-specific differences; nevertheless, the proportion of “trauma” patients in the emergency department of the UKL is comparable with the results of other studies, showing a proportion of 29% of patients classified as “injuries and effects of external factors“ (9).

In our study, the proportion of inpatient admissions among “trauma” patients is much smaller compared to the proportion among “non-trauma” patients. Given that at least one in two trauma patients referred by the rescue and emergency medical services had to be admitted to the hospital, the inpatient admission rate was, at 23%, significantly lower among the patients with trauma referred by community-based physicians. The finding that approximately 95% of the self-referred patients with a trauma-related leading symptom were discharged from the ED indicates that these patients could potentially be attended to in a community setting.

In contrast, the inpatient admission rate for non-trauma patients among the patients referred by community-based physicians was 41% compared to 21% among self-referred patients. These results are comparable with data from emergency departments in Munich, showing an inpatient admission rate for trauma patients of 23% and inpatient admission rates between 67% and 85% for patients with cardiovascular disease, respiratory disease and neurological disease (9).

The substantial number of patients discharged directly from the ED underscores the need for alternative outpatient care options, as well as better ways of directing of these patients.

Establishing general practitioner and portal practices as well as the emergency medical service in the hospital itself or in its immediate vicinity has been discussed on a federal level as possible solutions, at least since the expert report of the Advisory Council on the Assessment of Developments in the Health Care System (2018). Some of these projects are currently being piloted or have already been implemented (e2). However, the high rate of non-admissions among patients referred by community-based physicians indicates that diagnostic and therapeutic resources are not immediately available in this setting even during regular practice hours. Thus, especially trauma patients are often primarily referred for differential diagnostic exclusion of other injuries and not so much with the intention of admitting the patient to the hospital. This underscores that the resources required for this purpose (e.g., ultrasound, radiography and, if necessary, laboratory testing) are not regularly available in the community setting and would first have to be bindingly established there if the goal is to shift this workup to the outpatient setting. Thus, primary presentation of these patients to healthcare providers in the outpatient, community setting only makes sense from an economic point of view if a minimum level of equipment and qualifications as well as the range of services offered by such emergency practices are standardized and bindingly defined (e14). This should be taken into account when directing patients to the most appropriate area of care (2).

The establishment of adequately funded and, in particular, appropriately staffed emergency centers for the primary care of all acute and emergency patients should be evaluated in a way that does not prejudge the outcome (13).

At the time of writing, draft guidelines of the Federal Joint Committee (G-BA, Gemeinsamer Bundesausschuss) on the “Assessment of medical care needs of patients who seek emergency treatment at a hospital“ were available. From the perspective of the medical societies, however, the results of currently ongoing studies evaluating various dedicated initial assessment systems as well as ongoing pilot projects are yet to be seen (e15).

In our view, the regular collection of the parameters evaluated in this study—such as case type as a function of type of referral—can support the management of necessary capacities for the continued medical support of acute and emergency patients; however, it can also underscore the necessary scope of alternative treatment options.

Limitations

There are some limitations to this study: It was conducted with a monocentric design in an emergency department of a university hospital which may attend to a particularly severely ill or injured multimorbid patient population (e9, 17, 18). Further limitations are listed in eBox 6.

eBox 6

Additional information on limitations

Acknowledgement

We would like to thank the entire team of the emergency department of the University of Leipzig Medical Center for their commitment and dedicated work.

Conflict of interest statement
The authors declare no conflict of interest.

Manuscript received on 3 March 2022, revised version accepted on 5 July 2022

Translated from the original German by Ralf Thoene, MD.

Corresponding author

Prof. Dr. med. André Gries

Zentrale Notaufnahme/Beobachtungsstation Notaufnahme

Universitätsklinikum Leipzig AöR

Liebigstraße 20, 04103 Leipzig, Germany

Cite this as:
Gries A, Schrimpf AM, von Dercks N: Hospital emergency departments—utilization and resource deployment in the hospital as a function of the type of referral. Dtsch Arztebl Int 2022; 119: 640–6. DOI: 10.3238/arztebl.m2022.0276

►Supplementary material

eReferences, eBoxes, eTable:
www.aerzteblatt-international.de/m2022.0276

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