Emergency department (ED) overcrowding has grown in recent years. Most health system and political leaders believe that the culprit is too many low-acuity patients presenting to the ED, what are called “inappropriate” patients. The common wisdom is that these patients can and should seek treatment at lower-acuity, more appropriate sites of care. Governments, health systems, and payers are thus investing significantly in sites of care to serve as ED alternatives, to which they can ideally divert a substantial number of inappropriate ED presentations.

Stakeholders across the industry hope that a resulting reduction in inappropriate presentations will enable EDs to boost performance and reduce crowding to a manageable level.

Leaders are right when they say that a significant portion of ED presentations are by low-acuity patients who can be treated in ED alternatives. But the main source of ED capacity challenges, increases in wait times, and burdens on clinician time is the patient cohort that health systems and regulators view as “appropriate”: acute presentations that require time-sensitive interventions.

There are three factors that point to this reality:

1. Appropriate ED presentations are driving ED demand growth. The annual growth rate of appropriate ED visits far outpaces that of inappropriate visits. Acute ED presentations now make up a majority of total ED visits and will continue to increase in share.
2. Appropriate patients are the primary driver of ED wait time pressures. In fact, diverting low-acuity visits may worsen overall ED wait time performance.
3. There is limited opportunity to free up clinician time by diverting low-acuity visits. Just 6% of new demand on ED nurse time over the last decade was driven by low-acuity visit growth. The other 94% — a far greater opportunity for reduction — was driven by acute visit growth.

Ideally, systems and governments could invest in all possible solutions. But the scarcity of resources, investing in acute care efficiencies such as clinical decision support system (CDSS) technologies, longitudinal care management, hospital-in-the-home (HITH), and remote patient monitoring (RPM) tools are more sustainable solutions for addressing the root of the ED capacity problem than other popular investments such as building ED alternatives or urgent care clinics.