by Madeleine McDowell, MD, FAAP
Sg2 Principal and Medical Director of Quality and Strategy

Most health care services volumes are poised for a rapid recovery from the aftermath of the COVID-19 pandemic. However, a shift in where care is delivered that began before the pandemic has only accelerated and is particularly impacting emergency department demand.

Even while the Sg2 2021 Impact of Change® F­orecast predicts emergent ED visits to grow 5% over the next decade, low-acuity ED visits are expected to decline 15% during the same period. Patients who do present to the ED will be sicker and more likely to require comprehensive services, have a longer length of stay and have a higher likelihood of being admitted to the inpatient setting. Recent ED data from Vizient’s Clinical Data Base highlights this trend, with 21% of patients seen in the ED admitted to the hospital, up from 19% in 2019.

The main reason for the change

Low-acuity ED visits have been shifting to lower-cost alternative care sites, including physician offices, urgent-care clinics and virtual health triage services since 2017. The pandemic accelerated the trend as patients, following safety protocols, increasingly adopted these lower-cost sites of care.

But urgent care centers aren’t the only drivers in ED decline. New care models like the 2021 CMMI voluntary payment pilot, “Emergency Triage, Treat and Transport (ET3),” provide flexibility in where patients receive their care. In this pilot, ambulance care teams can triage patients in their home following a 911 call, and payment for transport to alternative care sites is provided, enabling lower acuity conditions to be directed to physician offices, urgent care clinics or community mental health clinics, in addition to the traditional hospital ED.

As low-acuity patients shift out of the ED and demand for higher acuity ED services grows due to rising chronic disease and an aging population, an overall increase in ED patient acuity and complexity is projected. In addition to the rise in acuity, an increase in behavioral health ED visits is expected to further impact the case-mix in the ED.

One bright note is that safeguards implemented to prevent the spread of COVID-19 reduced other infectious disease volumes as well as downstream viral-induced exacerbation of asthma and chronic obstructive pulmonary disease (COPD) during the pandemic. Pediatric infectious disease and asthma ED  visits were significantly down as well for 2020 when social distancing measures were enacted.

But as the pandemic eases in many parts of the county, and physical distancing guidelines are relaxed, ED volumes are expected to rebound, though not fully. The shift in lower acuity patients to lower-cost settings is here to stay. In the most recent ED data from the first half of 2021, Vizient Clinical Data Base showed ED visits down 14 % from 2019, with the lower acuity ED visits declining the most. In actuality, the highest acuity, Level 1 Emergency Severity Index (ESI) visit volume increased 2% above 2019 volumes in the second quarter of this year, an indicator of rising patient acuity.

Implications of rising patient acuity in the emergency department

Rising acuity and medical complexity in the ED will translate to longer ED lengths of stay and a higher percentage of ED patients who are admitted to the hospital. Managing throughput and transitions to the inpatient setting will be more important than ever. In addition, this has facility implications for EDs. Preparing for growth in geriatric and psychiatric ED patients may include the creation of separate units to optimally meet these patient populations’ unique needs. Geriatric EDs have proven beneficial in reducing avoidable admissions and bounce backs to the emergency department. Psychiatric EDs have reported shorter lengths of stay and time to treatment for these patients as well downstream benefits for the main ED of reduced bottlenecks as a result of separating this patient population.

The changes that will occur over the next decade were set in motion years before COVID-19 left its mark on health care, but in many instances, the pandemic has accelerated the changes. Emergency services will continue to transition from a fixed location (ED) to a network of settings in which care redesign, virtual technologies, payer pressures and consumer preferences will continue to drive shifts in lower acuity ED volumes to lower-cost settings. Offsetting this shift out of the ED will be a rising chronic disease burden, and increased demand for high acuity ED services, that will require hospitals to invest in new ways. 

About the author: Madeleine McDowell leverages a decade of clinical experience in leading the development and application of Sg2’s data analytic tools and providing clinical insight for all Sg2 research. As medical director, she provides thought leadership in quality in collaboration with experts across the Vizient and Sg2 organizations and partners with member health systems as a strategic advisor and health care industry expert in market strategy, quality and analytics. Her involvement with the annual updates of Sg2’s Impact of Change® forecasts and CARE Grouper ensures rigorous clinical oversight is applied. In addition, she oversees the development of new data analytic methodologies and integration with Vizient analytics. 

Published: November 11, 2021