Increasing Direct Admissions Safely With an Inclusive Guideline

Direct admission (DA) to the hospital bypasses the receiving hospital's emergency department (ED) and has been shown to offset ED overload without compromising patient safety. We aimed to increase the proportion of unscheduled admissions admitted directly.

We tracked DA to our children's hospital between January 1, 2021, and October 31, 2025. Interventions included centralization of unscheduled admissions within our Transfer Center, establishment of hospitalist attending oversight, and development of a DA guideline inclusive of all diagnoses, ages, and specialties. Interventions went live May 2023. Our primary outcome was the proportion of unscheduled admissions admitted directly, and our secondary outcome was ED length of stay (LOS) for patients admitted through the ED. Balancing measures included escalations of care within 6 hours, time to first clinical assessment, and hospitalization under 12 hours. We used descriptive statistics and statistical process control to assess the impact of our interventions.

DA increased from 12% preintervention to 18% postintervention without increasing intensive care transfers. During the same period, there was a sustained shift in ED LOS for admitted patients from 335 to 288 minutes. The median time to initial clinical assessment was 11 minutes faster for DA compared with ED admission (DA: 3 minutes, IQR 0-9 minutes vs ED: 14 minutes, IQR 7-30 minutes; P < .001). ED admissions were more likely to be hospitalized less than 12 hours (DA: 3.0% vs ED: 5.0%, P < .001).

A broadly inclusive DA guideline safely increased DA. Future work may explore adaptation within other health systems.