One roadblock to this work is ideologic and comes from our collective understanding of the specialty of emergency medicine. Emergency physicians have always prided themselves on providing whatever the patient needs in the moment, treating both emergencies and urgent unscheduled conditions. Now in this era of capacity crisis the specialty has met a new reality. Health care does not have infinite capacity. Health care delivery is a zero-sum game; if patient A receives a service it will not be available to patient B simultaneously. While health care delivery may not need rationing, it certainly needs sequencing and scheduling. This has led front-line emergency physicians to return to the demand side of the throughput equation.

This “avoidable admissions” movement to reduce demand for inpatient hospital capacity from the ED is sometimes dubbed the practical alternatives to hospitalization (PATH) movement.^33-35 Studies vary in how much this demand can be reduced, but this new and growing body of literature suggests that tactics can reduce avoidable admissions by 10 to 40 percent.

The avoidable admissions tactics can include a number of processes, initiatives and programs. Avoidable admissions can be addressed using an array of interconnected strategies:

1. Rapid follow-up appointments: A number of studies have shown that when there are timely follow-up appointments for ED patients, then avoidable admissions can be managed effectively.^36-38 Even next-day follow-up phone calls to check on discharged ED patients can help reduce admissions.³⁹
2. Deferred consultations or subspecialty appointments: One study from Norway recorded that 14 percent of ED admissions were due to a need for subspecialty consultations. The same study estimated that 21 percent of these subspecialty admissions could have been avoided.40 This is leading to efforts at improving care transitions through patient navigation and efficient centralized scheduling to avoid those admissions of stable ambulatory patients in need of subspecialty care.
3. ED observation unit (EDOU) or clinical decision unit: In another prospective survey of emergency physicians, reported in the American Journal of Emergency Medicine by Watase in 2020, front-line physicians estimated that one in seven unscheduled admissions could be avoided through an EDOU, to allow more time to address diagnostic uncertainty.⁴¹ A review in Health Services and Delivery Research identified Clinical Decision Units (CDUs) as having a similar effect.⁴²
4. Hospital at home programs: Certainly a Blue Ocean Strategy is the new field of inpatient-level care coordinated and delivered at home, referred to as the “hospital at home” movement.^43-46 Patients are very satisfied and prefer to be treated in their homes whenever possible. This is different from hospice care in that the expectation is for the patient to receive treatment for treatable conditions. At the University of Texas San Antonio, patients that may be eligible are referred in real time to the hospital at home team who can screen and enroll patients into this program. It is one of the fastest growing programs in the Texas University Health System.⁴⁷
5. Disease-specific pathways: When considering outpatient management of conditions that have been historically managed as inpatient conditions, there is an ongoing debate as to whether or not a disease-specific pathway approach is better than a patient-population–specific approach. Examples of conditions that are amenable to clinical pathways around the country include those for congestive heart failure, cellulitis, pneumonia, pyelonephritis, and chest pain.^48,49 An example of a patient-population approach is the EDIFY work for frail adults.⁵⁰
6. ED-based discharge teams: The last initiative that is getting traction in this avoidable admissions arena is one where a physician, nurse, care coordinator, or any combination of the three is placed in the ED to identify patients that might have their care plan adapted to an outpatient-care process model.^51-53
7. Direct nursing home or rehab placement from the ED: Lastly, EDs are experimenting with placement agreements which allow the ED to place appropriate patients in nursing homes or rehab units without a hospitalization first. The Watase study found that this would reduce unavoidable admissions by 20 percent.⁴² A new study in a Spanish gerontology journal reported success with direct admission to a nursing home from the ED.⁵⁴ This may be a new trend on the horizon.

When should you consider implementing the initiatives and tactics of a PATH program? If your hospital is constantly over capacity, with high numbers of hospital boarders every day, these initiatives are worth considering. Emergency physicians want to deliver high-quality, safe, and cost-effective care. That is not what we are delivering when admitted patients have long dwell times and there is no room to care for newly arriving patients. In fact, as a large body of literature shows, ED care suffers during boarding.