Untapped Potential for Emergency Department Observation Unit Use: A National Hospital Ambulatory Medical Care Survey (NHAMCS) Study

Abstract

Introduction: Millions of people present to the emergency department (ED) with chest pain annually. Accurate and timely risk stratification is important to identify potentially life-threatening conditions such as acute coronary syndrome (ACS). An ED-based observation unit can be used to rapidly evaluate patients and reduce ED crowding, but the practice is not universal. We estimated the number of current hospital admissions in the United States (US) eligible for ED-based observation services for patients with symptoms of ACS. Methods: In this cross-sectional analysis we used data from the 2011-2015 National Hospital Ambulatory Medical Care Survey (NHAMCS). Visits were included if patients presented with symptoms of ACS (eg, chest pain, dyspnea), had an electrocardiogram (ECG) and cardiac markers, and were admitted to the hospital. We excluded patients with any of the following: discharge diagnosis of myocardial infarction; cardiac arrest; congestive heart failure, or unstable angina; admission to an intensive care unit; hospital length of stay > 2 days; alteplase administration, central venous catheter insertion, cardiopulmonary resuscitation or endotracheal intubation; or admission after an initial ED observation stay. We extracted data on sociodemographics, hospital characteristics, triage level, disposition from the ED, and year of ED extracted from the NHAMCS. Descriptive statistics were performed using sampling weights to produce national estimates of ED visits. We provide medians with interquartile ranges for continuous variables and percentages with 95% confidence intervals for categorical variables. Results: During 2011-2015 there were an estimated 675,883,000 ED visits in the US. Of these, 14,353,000 patients with symptoms of ACS and an ED order for an ECG or cardiac markers were admitted to the hospital. We identified 1,883,000 visits that were amenable to ED observation services, where 987,000 (52.4%) were male patients, and 1,318,000 (70%) were White. Further-more, 739,000 (39.2%) and 234,000 (12.4%) were paid for by Medicare and Medicaid, respectively. The majority (45.1%) of observation-amenable hospitalizations were in the Southern US. Conclusion: Emergency department-based observation unit services for suspected ACS appear to be underused. Over half of potentially observation-amenable admissions were paid for by Medicare and Medicaid. Implementation of ED-based observation units would especially benefit hospitals and patients in the American South.