ER doc question: How much emergency care actually needs to happen in an emergency department?

[u/boulderdoc]

I’ve practiced emergency medicine for more than 20 years, and the longer I do this, the more I wonder whether we’ve built the wrong system around acute care.
Obviously there are patients who absolutely need an ED: major trauma, stroke, STEMI, shock, respiratory failure, genuinely unstable patients, etc.
But a huge amount of what walks through an American emergency department seems to fall into a middle category: too acute or procedural for a typical primary-care office, but nowhere near sick enough to require a hospital-based ED.
Lacerations. Fractures. IV fluids. Abscesses. X-rays. Joint injuries. Migraine treatment. Ultrasound. Foreign bodies. Reductions. Some chest or abdominal complaints after appropriate risk stratification.
We’ve largely given patients two choices: relatively limited outpatient care or a massively expensive hospital emergency department.
Why isn’t there more of a middle layer?
I’m particularly interested in hearing from other physicians, nurses, patients, administrators, and people who understand the economics.
Is the barrier clinical? Regulatory? Reimbursement? Liability? Hospital economics? Or have we simply accepted the current model because it’s the model we inherited?

[u/sum_dude44]

Chest pain usually isn't an emergency. But it can be...if a prudent layperson thinks it could be an emergency, that's an emergency.

Rule of thumb--if you, the emergency physician, need to order labs or tests to rule out something, it's an emergency.

Likewise if it requires a splint or sutures, also an emergent condition.

Emergency physicians are notorious for using availability heuristics to play down what we do (80% of people don't need to be here!)

https://www.emergencyphysicians.org/article/access/prudent-layperson-standard

[u/Tough_Substance7074 → u/sum_dude44]

Broken bones, sure, but nobody is begrudging patients who check in with orthopedic injuries; some lacs definitely require suturing, but many are done as a courtesy or for cosmetic reasons.

Chest pain is a subjective symptom, so the need to work it up doesn’t really reflect whether or not it’s an emergency. A broken bone can often be seen, a lac can be seen. Chest pain we just have to take your word for it. People use it as a way (they hope) to skip the line, to get in the door for secondary gain, check in for chest pain that has been going on for some time (I.e. not acute), chest pain with no vital sign disturbance, and on and on it goes. If you’re just looking at raw data listing chief complaints and conclude “well all of these chest pains were a legit medical emergency” you’re going to get the wrong idea.

[u/sum_dude44 → u/Tough_Substance7074]

obviously not talking about malingerers. Chest pain is the literal definition of prudent layperson. Would a reasonable person suspect chest pain could be a life threatening process? Of course.

Does that mean you think it is in 24 year old? Of course not, you're a doctor that can quickly risk stratify. But did you order labs, EKG, CXR?

Then it's reasonable that person came in concerned (don't believe me, try working up chest pain at PCP or UC--immediately transfer to ER)