#126 Delayed decision making in the emergency department: a before-and-after study of seven years of prospectively recorded data on the impact of ambulatory care by on-call teams in the emergency department

<h3>Introduction</h3> Admission rate (total admissions via ED/total attendances to ED) is a key performance indicator. Senior management in the study hospital proposed that if discharge by the on-call team within 24 hours was possible, the patient should be termed ‘ambulatory’ and remain in the ED instead of being admitted. This study was performed to assess the impact of this initiative on ED occupancy. <h3>Methods</h3> A before-and-after study of the impact of the ambulatory care initiative on ED admission rates and ED occupancy was performed. The number of patients under the care of the emergency medicine (EM) team and those under the admitting teams - referred, ambulatory, or boarded admitted patients in the ED - were documented at 08:00 from January 2017 to December 2023. The working hypothesis was that implementation of the ambulatory initiative should reduce admission rates albeit at the expense of increased ED occupancy i.e. crowding. <h3>Results</h3> Over the study period, admission rates increased. Using the Kruskal-Wallis test, a statistically significant difference (p&lt;0.05) between admission rates in the pre-intervention (0.26±0.002), during intervention (0.26±0.004), and post-intervention groups (0.27±0.002) was found. The total proportion of patients under the care of on-call teams in the ED did not differ (p=0.051). The proportion of patients in the ‘referred’ category increased significantly post-intervention (p&lt;0.05, figure 1). The proportion of admitted boarded patients decreased (p&lt;0.05, figure 2). The level of occupancy of the ED (number of patients/number of clinical care spaces) at 08:00 each day increased from 0.9±0.01 pre-intervention to 1.1±0.1 post-intervention (p&lt; 0.001). <h3>Discussion</h3> Ambulatory care did not reduce ED admission rates. Post-implementation, the proportion of ED patients ‘referred’ increased and the proportion of patients ‘boarded’ decreased. On-call teams performing extended work-ups in the ED occupies valuable clinical space required for patients needing assessment by the EM team.