The Great Debate: ED vs Direct Admission

Each year, two million children are admitted to the hospital. Drs. Leyenaar and McDaniel debated whether these patients should be admitted through the emergency department (ED) or directly. They examined critical issues, such as throughput, patient safety, and unanticipated deterioration. There remains high variability in what is perceived as an appropriate direct admission by diagnosis. While parents would prefer the direct admission process, a balance of appropriate safety and preparedness for the unit to accept the patient directly greatly impacts the appropriateness of direct admissions.

Practice guidelines can help with standardized care, but only just over one-third of hospitals reported having direct admission guidelines in 2016. A policy statement by the American Academy of Pediatrics was released in March 2023, which includes recommendations for written guidelines for direct admissions, clear systems of communication and triage, and an ongoing system of evaluation regarding processes and outcomes. 

Key Takeaways

• Direct admissions are more common than perceived and there is data to support its safety and timeliness.
• An American Academy of Pediatrics policy statement outlines recommendations to support local best practices.
• Trust between referring and accepting clinicians is an essential foundation.
• Intentionality toward equity in implementation is key to avoiding worsening disparities.

Dr. Schwenk

Dr. Schwenk is a pediatric hospitalist at Norton Children’s Hospital in Louisville, Ky., where he serves as a medical director of inpatient services. He is also a professor of pediatrics at the University of Louisville School of Medicine, a senior fellow of hospital medicine, and the current chair of the Pediatrics Special Interest Group executive council.