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Admission prediction rules: some limited promise, but far from proven
  1. Elaine Rabin
  1. Correspondence to Dr Elaine Rabin, Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA; elaine.rabin{at}

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The internationally shared problem of emergency department crowding appears to have generated an interest in admission prediction rules. These are not rules to predict which patients would benefit from an admission—a clinical question—but rather who will be admitted—an administrative question that has repercussions for the entire hospital system. These rules are conceptually different from the prediction rules usually encountered in medicine, which aim to provide clinicians with an evidence basis to better target testing and treatment in order to improve patient outcomes. The immediate goal of the admission prediction rules presented here is to improve the efficiency of care processes. So could these rules still benefit patients, or only hospital administrators? What is the potential utility of such rules? And do those presented here live up to that potential?

In their recent study from Australia, Ebker-White et al validate the Sydney Triage to Admission Risk Tool (START) previously designed for early identification of ED patients who will be discharged.1 The authors then develop an extended tool (START+) to identify patients expected to have lengths of stay of under 48 hours, that is, discharged directly from the ED or from short-stay units. Also in this issue, Kraaijvanger et al report on the development and validation of another admission prediction rule.2 In a previous issue of EMJ, Lucke et al proposed separate rules for patients older and younger than 70 years to predict admissions.3

Though these rules appear primarily concerned with administrative processes, very real improvements in patient outcomes could theoretically result if the rules’ implementation successfully decreases crowding in the ED. The international epidemic of hospital crowding continues, and a large literature demonstrates not only its association with increased morbidity, but even mortality effects.4 ED throughput problems are a minor contributor to crowding compared with impairments in overall patient flow …

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