An aging population, lack of access to primary care, staff shortages and not enough hospital beds — all are driving the chronic, critical overcrowding of U.S. emergency departments.
Many arrivals at hospital emergency departments end up “boarding” in beds squeezed into waiting rooms or lined up along noisy hallways. Nationwide in 2022, 2.5 million ED visits stretched into a second day, or longer, according to the Centers for Disease Control and Prevention.
At Vanderbilt University Hospital, a Level 1 trauma center, ED arrival volumes have increased 8% over last year. In response, the Department of Emergency Medicine and Vanderbilt University Medical Center have developed a post-ED rapid follow-up program for patients who can be referred safely to outpatient clinics for evaluation and treatment.
The program “has been successful and provided a safe alternative to hundreds of patients who would otherwise have been admitted, … often boarding in our ED for hours or days,” according to a report published this spring in the American Journal of Emergency Medicine.
“The rapid follow-up clinic program is a great example of how VUMC’s unique culture of collaboration and collegiality benefits our patients,” said Tyler Barrett, MD, MSCI, professor of Emergency Medicine and Associate Chief Medical Officer for Compliance at VUMC.
In 2022 an executive work group at VUMC determined that admissions to Vanderbilt University Hospital from the ED could be reduced safely by referring patients who met certain criteria for rapid follow-up to 27 primary care and specialty clinics in the Vanderbilt Health system.
As a first step, each of VUMC’s clinical departments added six appointments to the schedules of their outpatient primary care and specialty clinics — two on Monday and one on each of the remaining days of the workweek.
Clinic appointments are to be scheduled within three days of the referral order. Given that many patients arriving at the ED are under- or uninsured or lack access to primary care, the program waives financial preapproval and additional out-of-network costs.
A new post-ED rapid follow-up clinic order was created for ED physicians and advanced practice providers to share with the Patient Transfer Center for scheduling. Educational materials about the new program are available electronically and in print, and a clinical decision support pathway helps physicians complete the process.
Patients scheduled for a rapid follow-up clinic appointment are assigned a unique ambulatory visit type so that finance representatives know not to call them. A call about the bill could discourage some patients from keeping their appointments.
In 2023, the first year of the program, 735 patients were referred for rapid outpatient clinic follow-up, out of nearly 76,000 ED encounters that year.
Clinic visits were scheduled for 632 patients, and 518 of them (82%) made it to their rapid follow-up appointments.
“Our Emergency Medicine team enthusiastically adopted this new disposition option and engaged patients and their families in shared decision-making discussions about hospital admission or rapid outpatient follow-up,” Barrett said. “Patients often preferred … returning for a scheduled clinic appointment the following day with a VUMC specialist or primary care clinician.”
The most common complaint among patients was chest pain (104 patients), followed by acute abdominal pain, palpitations and shortness of breath.
A safety review found that 74 (10%) of the 735 patients discharged from the ED returned to a Vanderbilt ED within a week. Twenty-six patients were admitted to the hospital on the repeat visit but none to an intensive care or intermediate care unit.
“The cardiovascular service line has been a proud partner in this important effort to ensure patients get the right care in the right venue, all while optimizing the utilization of inpatient resources,” said Daniel Muñoz, MD, associate professor of Medicine and executive medical director for the Vanderbilt Heart and Vascular Institute.
“We regularly evaluate these patients in our outpatient clinics,” Muñoz said. “A key factor in the success and sustainability of this program has been excellent, highly appropriate patient selection by our Emergency Medicine colleagues.”
This experience suggests that a rapid post-ED follow-up program “can safely avert admissions by increasing access to timely outpatient care,” the researchers concluded. The program frees beds for patients requiring more acute care while shifting resources, including radiology, laboratory and consultation services, to the outpatient setting.
The evaluation of the program was conducted and reported by Barrett and four other current Department of Emergency Medicine faculty members:
- Doug Wallace, MD, medical director, VUH Emergency Medicine
- Blayke Gibson, MD, MBA, director of Strategy and Innovation, Emergency Medicine
- Nathaniel Miller, MD, MMHC, executive director, Regional Emergency Medicine
- Stephan Russ, MD, MPH, executive medical director, Vanderbilt LifeFlight
Other VUMC co-authors were:
- Chetan Aher, MD, Associate Chief Medical Officer, Adult Ambulatory Clinics
- Patty Wright, MD, Chief Medical Officer, Adult Ambulatory Clinics
- Justin Young, MBA, senior associate, Office of the Chief Medical Officer
- Mitchell Sexton, MBA, principal analytics consultant
- Schiara Gonzalez Parker, BSN, MBA, senior director, Patient Flow Center
