In residency, we had a term for ER docs who always seemed to find an excuse to admit patients to the hospital. We called them sieves. A newly admitted patient would arrive to 5 West, we would talk to and examine them, study their tests, and wonder how the heck they found their way to a hospital bed until, inevitably, we would realize: “Dr. S is working the ER tonight!”
I always wondered whether our judgments of these sieve-like physicians were simply a function of our exhausted desire to have a less overwhelming workload. Maybe these ER docs are being on the cautious side, but perhaps their better-safe-than-sorry judgments are saving the occasional patient’s life.
Recent evidence suggests that sieves in the ER drive up costs, workloads, and hospital utilization; but they do not save lives.
The study looked at data from more than 100 VA hospitals, and evaluated three groups of patients – those coming to the emergency department with:
1. Chest pain
2. Shortness of breath, or
3. Abdominal pain
The researchers evaluated the decisions of more than 2000 physicians, plotting out the chance that each physician would admit patients with one of these three problems. Two findings are notable.
First, hospital length of stay was significantly shorter for patients admitted by physicians who have high admission rates, i.e. the sieves. That was especially true for patients with chest pain. Here is a picture of that finding, with the chance of a short admission rising as we move from left to right, from physicians who make more parsimonious admission decisions to those with lower thresholds for sending people into the hospital.
This figure shows that questionable admissions are often addressed by discharging patients home once their clinical stability has been demonstrated. But it does not tell us whether, in the midst of all these extra admissions, some patients’ lives were saved. It doesn’t show whether a subset of patients was discovered to have serious illness, their lives now saved by receiving hospital care.
As it turns out, ER physicians who have high admission rates do not impact patient mortality. Here’s a picture showing that finding:
Look, medicine is tough. It is hard to evaluate someone with chest pain, in the midst of a busy ER shift, and know, absolutely know, that they are safe to go home. It is understandable that many physicians, when in doubt, resort to better-safe-than-sorry reasoning.
The problem is that while these physicians are being safe, everyone else has reason to be sorry. Those unnecessarily admitted patients faced risks associated with being in the hospital, in addition to the burden and cost of the admission.Moreover, hospital employees were forced to expend effort on patients who did not need their help. And the system as a whole – the insurance companies, the people paying insurance premiums, the taxpayers covering the cost of Medicare, Medicaid, and the VA – ended up responsible for the cost of this unnecessary care.
Many hospitals now face pressures to hold down spending. That often plays out in actions they take to make hospital stays more efficient. As this study shows, they should also look closely at ways to keep overly-cautious physicians from admitting patients who don’t require hospital stays.
