Hospital Emergency Departments
Crowding Continues to Occur, and Some Patients Wait Longer than Recommended Time Frames Gao ID: GAO-09-347 April 30, 2009Hospital emergency departments are a major part of the nation's health care safety net. Of the estimated 119 million visits to U.S. emergency departments in 2006, over 40 percent were paid for by federally-supported programs. These programs--Medicare, Medicaid, and the State Children's Health Insurance Program--are administered by the Department of Health and Human Services (HHS). There have been reports of crowded conditions in emergency departments, often associated with adverse effects on patient quality of care. In 2003, GAO reported that most emergency departments in metropolitan areas experienced some degree of crowding (Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities, GAO-03-460). For example, two out of every three metropolitan hospitals reported going on ambulance diversion--asking ambulances to bypass their emergency departments and instead transport patients to other facilities. GAO was asked to examine information made available since 2003 on emergency department crowding. GAO examined three indicators of emergency department crowding--ambulance diversion, wait times, and patient boarding--and factors that contribute to crowding. To conduct this work, GAO reviewed national data; conducted a literature review of 197 articles; and interviewed officials from HHS and professional and research organizations, and individual subject-matter experts.
Emergency department crowding continues to occur in hospital emergency departments according to national data, articles we reviewed, and officials we interviewed. National data show that hospitals continue to divert ambulances, with about one-fourth of hospitals reporting going on diversion at least once in 2006. National data also indicate that wait times in the emergency department increased, and in some cases exceeded recommended time frames. For example, the average wait time to see a physician for emergent patients--those patients who should be seen in 1 to 14 minutes--was 37 minutes in 2006, more than twice as long as recommended for their level of urgency. Boarding of patients in the emergency department who are awaiting transfer to an inpatient bed or another facility continues to be reported as a problem in articles we reviewed and by officials we interviewed, but national data on the extent to which this occurs are limited. Moreover, some of the articles we reviewed discussed strategies to address crowding, but these strategies have not been assessed on a state or national level. Articles we reviewed and individual subject-matter experts we interviewed reported that a lack of access to inpatient beds continues to be the main factor contributing to emergency department crowding, although additional factors may contribute. One reason for a lack of access to inpatient beds is competition between hospital admissions from the emergency department and scheduled admissions--for example, for elective surgeries, which may be more profitable for the hospital. Additional factors may contribute to emergency department crowding, including patients' lack of access to primary care services or a shortage of available on-call specialists. In commenting on a draft of this report, HHS noted that the report demonstrates that emergency department wait times are continuing to increase and frequently exceed national standards. HHS also provided technical comments, which we incorporated as appropriate.
GAO-09-347, Hospital Emergency Departments: Crowding Continues to Occur, and Some Patients Wait Longer than Recommended Time Frames
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Report to the Chairman, Committee on Finance, U.S. Senate:
United States Government Accountability Office:
GAO:
April 2009:
Hospital Emergency Departments:
Crowding Continues to Occur, and Some Patients Wait Longer than
Recommended Time Frames:
GAO-09-347:
GAO Highlights:
Highlights of GAO-09-347, a report to the Chairman, Committee on
Finance, U.S. Senate.
Why GAO Did This Study:
Hospital emergency departments are a major part of the nation‘s health
care safety net. Of the estimated 119 million visits to U.S. emergency
departments in 2006, over 40 percent were paid for by federally-
supported programs. These programs”Medicare, Medicaid, and the State
Children‘s Health Insurance Program”are administered by the Department
of Health and Human Services (HHS). There have been reports of crowded
conditions in emergency departments, often associated with adverse
effects on patient quality of care. In 2003, GAO reported that most
emergency departments in metropolitan areas experienced some degree of
crowding (Hospital Emergency Departments: Crowded Conditions Vary among
Hospitals and Communities, GAO-03-460). For example, two out of every
three metropolitan hospitals reported going on ambulance diversion”
asking ambulances to bypass their emergency departments and instead
transport patients to other facilities.
GAO was asked to examine information made available since 2003 on
emergency department crowding. GAO examined three indicators of
emergency department crowding”ambulance diversion, wait times, and
patient boarding”and factors that contribute to crowding. To conduct
this work, GAO reviewed national data; conducted a literature review of
197 articles; and interviewed officials from HHS and professional and
research organizations, and individual subject-matter experts.
What GAO Found:
Emergency department crowding continues to occur in hospital emergency
departments according to national data, articles we reviewed, and
officials we interviewed. National data show that hospitals continue to
divert ambulances, with about one-fourth of hospitals reporting going
on diversion at least once in 2006. National data also indicate that
wait times in the emergency department increased, and in some cases
exceeded recommended time frames. For example, the average wait time to
see a physician for emergent patients”those patients who should be seen
in 1 to 14 minutes”was 37 minutes in 2006, more than twice as long as
recommended for their level of urgency. Boarding of patients in the
emergency department who are awaiting transfer to an inpatient bed or
another facility continues to be reported as a problem in articles we
reviewed and by officials we interviewed, but national data on the
extent to which this occurs are limited. Moreover, some of the articles
we reviewed discussed strategies to address crowding, but these
strategies have not been assessed on a state or national level.
Table: Average Wait Time to See a Physician and Percentage of Visits in
Which Wait Time to See a Physician Exceeded Recommended Time Frames by
Acuity Level, 2006:
Patient acuity level[A] (recommended time frame): Immediate (less than
1 minute);
Average wait time in minutes: 28;
Percentage of visits in which wait time exceeded recommended time
frames: 73.9.
Patient acuity level[A] (recommended time frame): Emergent (1 to 14
minutes);
Average wait time in minutes: 37;
Percentage of visits in which wait time exceeded recommended time
frames: 50.4.
Patient acuity level[A] (recommended time frame): Urgent (15 to 60
minutes);
Average wait time in minutes: 50;
Percentage of visits in which wait time exceeded recommended time
frames: 20.7.
Patient acuity level[A] (recommended time frame): Semiurgent (greater
than 1 to 2 hours);
Average wait time in minutes: 68;
Percentage of visits in which wait time exceeded recommended time
frames: 13.3.
Patient acuity level[A] (recommended time frame): Nonurgent (greater
than 2 to 24 hours);
Average wait time in minutes: 76;
Percentage of visits in which wait time exceeded recommended time
frames: [B].
Source: GAO analysis of data from HHS‘s National Center for Health
Statistics (NCHS).
Notes: Information on the standard error associated with estimates of
averages is found in the report.
[A] Acuity levels describe the recommended time a patient should wait
to be seen by a physician. NCHS developed acuity levels based on a five-
level emergency severity index recommended by the Emergency Nurses
Association.
[B] In 2006, no emergency departments reported visits with wait times
in excess of 24 hours.
[End of table]
Articles we reviewed and individual subject-matter experts we
interviewed reported that a lack of access to inpatient beds continues
to be the main factor contributing to emergency department crowding,
although additional factors may contribute. One reason for a lack of
access to inpatient beds is competition between hospital admissions
from the emergency department and scheduled admissions”for example, for
elective surgeries, which may be more profitable for the hospital.
Additional factors may contribute to emergency department crowding,
including patients‘ lack of access to primary care services or a
shortage of available on-call specialists.
In commenting on a draft of this report, HHS noted that the report
demonstrates that emergency department wait times are continuing to
increase and frequently exceed national standards. HHS also provided
technical comments, which we incorporated as appropriate.
View [hyperlink, http://www.gao.gov/products/GAO-09-347] or key
components. To view the e-supplement to this report online, click on
GAO-09-348SP. For more information, contact Marcia Crosse at (202) 512-
7114 or crossem@gao.gov.
[End of section]
Contents:
Letter:
Background:
According to Indicators, Emergency Department Crowding Continues:
Available Information Suggests Lack of Access to Inpatient Beds Is the
Main Factor Contributing to Crowding, and Other Factors May Also
Contribute:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Emergency Department Utilization, 2001 through 2006:
Appendix III: Proposed Measures of Emergency Department Crowding:
Appendix IV: Emergency Department Wait Times:
Appendix V: Comments from the Department of Health and Human Services:
Appendix VI: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Number of Emergency Departments and Emergency Department
Visits in 2001 through 2006:
Table 2: Indicators of Emergency Department Crowding:
Table 3: Percentage of Hospitals That Reported Going on Diversion, and
Average Hours Hospitals Spent on Diversion in 2003 through 2006:
Table 4: Average Length of Stay in the Emergency Department, in
Minutes, and Percentage of Visits in Which Patients Left before a
Medical Evaluation in 2001 and 2006:
Table 5: Strategies to Address Indicators of Emergency Department
Crowding:
Table 6: Number of Articles Reviewed That Reported Factors Contributing
to Emergency Department Crowding:
Table 7: Percentage of Emergency Departments by Hospital Ownership
Type, Geographic Region, and Type of Area in 2001 through 2006:
Table 8: Number and Percentage of Emergency Department Visits by Payer
Source in 2001 through 2006:
Table 9: Number and Percentage of Emergency Department Visits by
Hospital Ownership Type, Geographic Region, and Type of Area in 2001
through 2006:
Table 10: Number and Percentage of Emergency Department Visits That
Resulted in Hospital Admissions in 2001 through 2006:
Table 11: Proposed Measures of Emergency Department Crowding:
Table 12: Percentage of Emergency Department Visits by Wait Time to See
a Physician, in 2003 through 2006:
Table 13: Average Wait Time to See a Physician, in Minutes, by Payer
Type, Hospital Type, and Geographic Region, in 2003 through 2006:
Table 14: Average Wait Time to See a Physician, in Minutes, by
Hospitals' Percentage of Visits in Which Patients Left before a Medical
Evaluation, in 2003 through 2006:
Table 15: Percentage of Visits by Emergency Department Length of Stay,
in 2001 through 2006:
Table 16: Average Length of Stay in the Emergency Department, in
Minutes, by Payer Type, Hospital Type, and Geographic Region, in 2001
through 2006:
Table 17: Average Length of Stay in the Emergency Department, in
Minutes, by Hospitals' Percentage of Visits in Which Patients Left
Before a Medical Evaluation, in 2001 through 2006:
Figures:
Figure 1: Percentage of Emergency Departments and Emergency Department
Visits in Metropolitan and Nonmetropolitan Areas in 2006:
Figure 2: Percentage of Emergency Department Visits by Acuity Level in
2006:
Figure 3: Input-Throughput-Output Model of Emergency Department
Crowding:
Figure 4: Average Wait Time to See a Physician, and Percentage of
Visits in Which Wait Time to See a Physician Exceeded Recommended Time
Frames by Acuity Level in 2003 and 2006:
Figure 5: Number and Percentage of Emergency Department Visits by
Acuity Level in 2001 through 2006:
Figure 6: Average and Median Wait Time to See a Physician, in Minutes,
by Acuity Level, in 2003 through 2006:
Figure 7: Average and Median Length of Stay in the Emergency
Department, in Minutes, by Acuity Level, in 2001 through 2006:
Abbreviations:
ACEP: American College of Emergency Physicians:
AHRQ: Agency for Healthcare Research and Quality:
DRG: diagnosis-related group:
HHS: Department of Health and Human Services:
IOM: Institute of Medicine:
NCHS: National Center for Health Statistics:
NHAMCS: National Hospital Ambulatory Medical Care Survey:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
April 30, 2009:
The Honorable Max Baucus:
Chairman:
Committee on Finance:
United States Senate:
Dear Mr. Chairman:
Open 24 hours a day, 7 days a week, hospital emergency departments are
a major part of the nation's health care safety net. Of the estimated
119 million visits to U.S. emergency departments in 2006, over 40
percent were paid for by federally-supported programs.[Footnote 1]
These programs--Medicare, Medicaid, and the State Children's Health
Insurance Program[Footnote 2]--are administered by the Department of
Health and Human Services (HHS). Emergency department staff report
being under increasing pressure, and concerns have been raised that
they face challenges in providing timely and effective emergency
medical care. For example, considerable attention has been given to
reports of ambulance diversion--that is, emergency departments
requesting that ambulances that would normally bring patients to their
hospitals go instead to other hospitals that are presumably less
crowded. Concerns have also been raised about the frequency of patients
remaining in the emergency department--taking up staff and resources--
after the decision has been made to admit them to the hospital or
transfer them to another facility, a practice known as boarding. In
addition, reports of long wait times in emergency departments have led
to concerns of potential adverse effects on the quality of care for
patients, such as prolonged pain and suffering.
We have reported on the extent of crowding in emergency departments and
factors contributing to crowding. In 2003, we reported results from our
survey of more than 2,000 hospitals with emergency departments located
in metropolitan areas of the country and from our site visits to
communities where media and other sources had reported problems with
emergency department crowding.[Footnote 3] Using three indicators of
crowding--diversion, patients leaving the emergency department before a
medical evaluation (presumably due to long wait times in the emergency
department), and boarding--we found that while most emergency
departments across the country experienced some degree of crowding,
[Footnote 4] crowding was much more pronounced in some hospitals and
areas than in others. Generally, hospitals that reported the most
problems with emergency department crowding were in metropolitan areas
with populations of 2.5 million or more. We also found that crowding is
a complex issue and that one key factor contributing to crowding at
many hospitals was the inability of hospitals to move admitted patients
out of emergency departments and into inpatient beds. Reasons given for
why hospitals did not have the capacity to meet demand for inpatient
beds from emergency department patients included financial pressures
leading to limited hospital capacity and competition between admissions
from the emergency department and scheduled admissions, such as for
elective surgery. Finally, we reported on strategies that were
implemented to address emergency department crowding in the six
communities that we visited; however, we found that studies assessing
the effect of these efforts were limited.
Since our 2003 report, Congress and others have raised concerns that
hospital emergency departments are continuing to experience crowded
conditions that could potentially compromise the nation's ability to
provide effective emergency medical care. For example, in September
2003 the Institute of Medicine (IOM) convened a committee to examine,
among other things, emergency department crowding.[Footnote 5] In
addition, in June 2007 the House Committee on Oversight and Government
Reform held a hearing at which experts in hospital emergency care
testified on the state of the nation's emergency care. Given this
continued interest, you asked to us to report on information made
available with respect to emergency department crowding since we issued
our 2003 report. Specifically, this report examines information made
available about (1) three indicators of emergency department crowding-
-ambulance diversion, wait times,[Footnote 6] and patient boarding, and
(2) factors that contribute to emergency department crowding.
To conduct this work, we reviewed national data, conducted a literature
review, and interviewed federal and other officials. First, we obtained
and reviewed national data on emergency department diversion and wait
times for 2001 through 2006 from the National Center for Health
Statistics (NCHS)[Footnote 7] and data on hospital admissions--which
were related to factors of crowding--from the Agency for Healthcare
Research and Quality (AHRQ).[Footnote 8] We obtained nationally-
representative data from NCHS and AHRQ beginning with 2001 because
these data became publicly available in 2003 or later, meeting the
criterion for inclusion in our analysis. At the time we conducted our
analysis, the most recent year for which data were available from NCHS
and AHRQ was 2006. In addition, some data from NCHS were not available
for all years between 2001 and 2006 because of revisions made by NCHS
to questions on surveys used to collect information or a low response
rate to certain questions on these surveys. As part of our review of
available national data on emergency department diversion and wait
times, we analyzed wait times in the emergency department using NCHS's
data on recommended time for a patient to see a physician based on
patient acuity levels.[Footnote 9] We also reviewed national data on
emergency department utilization to set up a context for our work. In
this report, we present NCHS estimates; for those cases in which we
report an increase or other comparison of these estimates, NCHS tested
the differences and found them statistically significant.[Footnote 10]
To assess the reliability of national data from NCHS and AHRQ, we
discussed the data with agency officials and reviewed the methods they
used for collecting and reporting these data. We resolved discrepancies
we found between the data provided to us and data in published reports
by corresponding with officials from NCHS to obtain sufficient
explanations for the differences. Based on these steps, we determined
that these data were sufficiently reliable for our purposes.
We also conducted a literature review of 197 articles, including
articles published in peer-reviewed and other periodicals, publications
from professional and research organizations, and reports issued by
federal and state agencies. In examining the information made available
since 2003 about indicators of crowding during our literature review,
we analyzed articles for what was reported on the effect of crowding on
patient quality of care and on proposed strategies to address crowding.
We reviewed 197 articles, publications, and reports (which we call
articles)[Footnote 11] on emergency department crowding published on or
between January 1, 2003, and August 31, 2008. These included articles
reporting on results of surveys conducted by the American College of
Emergency Physicians (ACEP) and the American Hospital Association that
provided information on ambulance diversion that was not available from
NCHS. A complete bibliography for the literature review can be viewed
at GAO-09-348SP.
Finally, we interviewed officials from federal agencies and one state
agency, professional and research organizations, other hospital-
related organizations, and individual subject-matter experts to obtain
and review information on indicators of emergency department crowding
and factors that contribute to crowding. We interviewed federal
officials from HHS's Centers for Medicare & Medicaid Services and the
Office of the Assistant Secretary for Preparedness and Response, and
officials from NCHS and AHRQ who have conducted research on emergency
department utilization and crowding. We also interviewed officials from
professional and research organizations, including ACEP, the American
Hospital Association, the American Medical Association, the Center for
Studying Health System Change, and the Society for Academic Emergency
Medicine. Some of the officials from ACEP and the Society for Academic
Emergency Medicine whom we interviewed have also published research in
peer-reviewed journals. Additionally, we interviewed hospital-related
organizations, including those involved in hospital accreditation and
in developing quality measures for hospital emergency department care,
and officials from the Massachusetts Department of Public Health.
Finally, we interviewed three individual subject-matter experts
knowledgeable about emergency department crowding. Additional
information about our methodology can be found in appendix I.
We conducted this performance audit from May 2008 through April 2009 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background:
Thousands of emergency departments operate in the United States, seeing
millions of patients each year. In our 2003 report on emergency
department crowding, we reported on the extent of crowding in
metropolitan areas. Researchers have used three indicators--diversion,
wait times, and boarding--in examining emergency department crowding.
Emergency Department Utilization:
Between 2001 and 2006, according to NCHS estimates, the number of
emergency departments operating in the United States ranged from about
4,600 to about 4,900.[Footnote 12] During the same period, the
estimated number of visits to U.S. emergency departments exceeded 107
million visits each year, ranging from about 107 million visits in 2001
to about 119 million visits in 2006. (See table 1.)
Table 1: Number of Emergency Departments and Emergency Department
Visits in 2001 through 2006 (In thousands):
Total number of emergency departments operating:
2001: 4.6;
2002: 4.9;
2003: 4.7;
2004: 4.7;
2005: 4.6;
2006: 4.8.
Total annual emergency department visit volume:
2001: 107,490;
2002: 110,155;
2003: 113,903;
2004: 110,216;
2005: 115,323;
2006: 119,191.
Source: GAO analysis of NCHS data.
Note: All estimates in this table are nationally representative. NCHS
estimates the number of hospitals with an emergency department in the
United States that is staffed and operated 24 hours a day.
[End of table]
Most hospitals with emergency departments are located in metropolitan
areas, and the majority of emergency department visits occurred in
metropolitan areas of the United States.[Footnote 13] In 2006, about
two-thirds of hospitals with emergency departments were located in
metropolitan areas compared to about one-third in nonmetropolitan
areas. In the same year, about 101 million (85 percent) of the
approximately 119 million emergency department visits occurred in
metropolitan areas compared to about 18 million (15 percent) visits in
nonmetropolitan areas. (See figure 1.)
Figure 1: Percentage of Emergency Departments and Emergency Department
Visits in Metropolitan and Nonmetropolitan Areas in 2006:
[Refer to PDF for image: two pie-charts]
Percentage of emergency departments:
Metropolitan: 66%;
Nonmetropolitan: 34%.
Percentage of emergency departments visits:
Metropolitan: 85%;
Nonmetropolitan: 15%.
Source: GAO analysis of NCHS data.
[End of figure]
Patients come to the emergency department with illnesses or injuries of
varying severity, referred to as acuity level. Each acuity level
corresponds to a recommended time frame for being seen by a physician-
-for example, patients with immediate conditions should be seen within
1 minute and patients with emergent conditions should be seen within 1
to 14 minutes. In 2006, urgent patients--patients who are recommended
to be seen by a physician within 15 to 60 minutes--accounted for the
highest percentage of visits to the emergency department. (See figure
2.)
Figure 2: Percentage of Emergency Department Visits by Acuity Level in
2006:
[Refer to PDF for image: pie-chart]
Percentage of Emergency Department Visits by Acuity Level in 2006:
Urgent: 37%;
Semiurgent: 22%;
No triage/unknown: 13%;
Nonurgent: 12%;
Emergent: 11%;
Immediate: 5%.
Source: GAO analysis of NCHS data.
Note: NCHS developed time-based acuity levels based on a five-level
emergency severity index recommended by the Emergency Nurses
Association. The acuity levels describe the recommended amount of time
a patient should wait to be seen by a physician. The recommended time
frames to see a physician are less than 1 minute for immediate
patients, between 1 and 14 minutes for emergent patients, between 15
minutes and 1 hour for urgent patients, greater than 1 hour to 2 hours
for semiurgent patients, and greater than 2 hours to 24 hours for
nonurgent patients.
[End of figure]
The expected sources of payment[Footnote 14] reported for patients
receiving emergency department services also vary. For example, from
2001 through 2006 patients with private insurance accounted for the
highest number and percentage of visits to the emergency department.
During the same period, the percentage of uninsured patients[Footnote
15] seeking care in emergency departments ranged between 15 and 17
percent of total visits, and the percentage of patients visiting
emergency departments with Medicare ranged between 14 and 16 percent.
See appendix II for additional data on expected sources of payment and
emergency department utilization.
Key Findings from the 2003 GAO Report on Emergency Department Crowding:
In 2003, using three indicators that point to situations in which
crowding is likely occurring--diversion,[Footnote 16] patients leaving
before a medical evaluation, and boarding--we reported that emergency
department crowding varied nationwide. We also reported that crowding
was more pronounced in certain types of communities, and that crowding
occurred more frequently in hospitals located in metropolitan areas
with larger populations, higher population growth, and higher levels of
uninsurance. We reported that crowding was more evident in certain
types of hospitals, such as in hospitals with higher numbers of staffed
beds, teaching hospitals, public hospitals, and hospitals designated as
certified trauma centers.
In terms of factors that contribute to crowding, we reported that
crowding is a complex issue and no single factor tends to explain why
crowding occurs. However, we found that one key factor contributing to
crowding was the availability of inpatient beds for patients admitted
to the hospital from the emergency department. Reasons given by
hospital officials and researchers we interviewed for not always having
enough inpatient beds to meet demand from emergency patients included
economic factors that influence hospitals' capability to meet periodic
spikes in demand and emergency department admissions competing with
other admissions for inpatient beds. Other additional factors cited by
researchers and hospital officials as contributing to crowding included
the lack of availability of physicians and other community services--
such as psychiatric services--and the fact that emergency patients are
older, have more complex conditions, and have more treatment and tests
provided in the emergency department than in prior years.
Further, we reported that hospitals and communities had conducted a
wide range of activities to manage crowding in emergency departments,
but that problems with crowding persisted in spite of these efforts.
These activities included efforts to expand capacity and increase
efficiency in hospitals, and community activities to implement systems
and rules to manage diversion. These efforts were unable to reverse
crowding trends at hospital emergency departments, and we found that
studies assessing the effect of these efforts were limited.
Indicators of Emergency Department Crowding:
Researchers use the indicators we reported on in 2003 to point to
situations in which crowding is likely occurring in emergency
departments.[Footnote 17] These indicators can point to when crowding
is likely occurring but they also have limitations. For example,
patients boarding in the emergency department can indicate that the
department's capacity to treat additional patients is diminished, but
it is possible for several patients to be boarding while the emergency
department has available treatment spaces to see additional patients.
Table 2 provides the definition of the three indicators of emergency
department crowding we reviewed in this report--diversion, wait times,
and boarding--and lists the usefulness and limitations of using these
indicators to gauge crowding. Regarding wait times, in our 2003 report,
we used "left before a medical evaluation" as an indicator of crowding
related to long wait times in an emergency department. Since we issued
our report in 2003, researchers have used intervals of wait times--
including the length of time to see a physician and the total length of
time a patient is in the emergency department--to indicate when an
emergency department is crowded. As a result, for this report, we
examined wait times more broadly, including data on the time for
patients to see a physician, length of stay in the emergency
department, and visits in which the patient left before a medical
evaluation.[Footnote 18]
Table 2: Indicators of Emergency Department Crowding:
Indicator: Ambulance diversion;
Definition: Hospitals request that ambulances bypass their emergency
departments and transport patients to other medical facilities;
Usefulness: For emergency departments where local rules permit
diversion, diversion is an indicator of how often emergency departments
believe that they cannot safely handle additional ambulance patients;
Limitations: The number of hours on diversion is a potentially
imprecise measure of crowding because whether a hospital can go on
diversion and the circumstances under which it can do so vary from
location to location, according to both individual hospital policy and
communitywide guidelines or rules.
Indicator: Wait times;
Definition: Intervals of wait time include the amount of time a patient
waits in the emergency department to see a physician, the percentage of
visits in which patients left before a medical evaluation, and the
total length of time a patient spends in the emergency department;
Usefulness: Long wait times can occur when an emergency department is
crowded and unable to treat patients waiting to be seen in a reasonable
amount of time. Excessive wait time is the most common reason patients
leave the emergency department before being treated;
Limitations: Since emergency department staff triage patients, those
with conditions that do not present an immediate emergency generally
wait the longest. These patients may also be most likely to tire of
waiting and leave before receiving a medical evaluation. In addition,
because there are several ways to measure wait times, it can be
difficult to compare wait times across hospitals or studies.
Indicator: Patient boarding;
Definition: A patient remains in the emergency department after the
decision to admit or transfer the patient has been made, for example
because an inpatient bed elsewhere in the hospital is not yet
available;
Usefulness: Patients boarding in the emergency department take up space
and resources that could be used to treat other emergency department
patients. Boarding is an indicator that an emergency department's
capacity to treat additional patients is diminished;
Limitations: Boarding does not always indicate that an emergency
department is crowded since it is possible for an emergency department
to be boarding patients while also having available treatment spaces.
Source: GAO.
[End of table]
Researchers have developed a conceptual model to analyze the factors
that contribute to emergency department crowding and develop potential
solutions.[Footnote 19] This model partitions emergency department
crowding into three interdependent components: input, throughput, and
output. Although factors in many different parts of the health care
system may contribute to emergency department crowding, the model
focuses on crowding from the perspective of the emergency department.
(See figure 3.)
Figure 3: Input-Throughput-Output Model of Emergency Department
Crowding:
[Refer to PDF for image: illustration]
Input (Community):
Patient demand for emergency department care prior to arrival at the
emergency department. Demand may be affected by access to health care
elsewhere in the community.
Throughput (Emergency Department):
Patient treatment experiences in the emergency department, including
triage, diagnostic evaluation, and physician treatment.
Output (Rest of hospital):
Patient dispositions following emergency department treatment,
including discharge from the emergency department, hospital admission,
and transfer to another facility.
Source: GAO analysis of published literature, Art Explosion (graphics).
[End of figure]
Researchers have used the input-throughput-output model to explain the
connection between factors that contribute to emergency department
crowding and indicators of crowding. The three indicators of emergency
department crowding--diversion, wait times, and boarding--are most
directly related to the input, throughput, and output components,
respectively, of the model; but the causes of these indicators can
relate to other components. For example, a hospital emergency
department might experience long wait times--an indicator associated
with the throughput component--because of delays in patients receiving
laboratory results (related to throughput) or because staff are busy
caring for patients boarding in the emergency department due to a lack
of access to inpatient beds (related to output). Similarly, an
emergency department may divert ambulances (related to input) because
the emergency department is full due to the inability of hospital staff
to move admitted patients to hospital inpatient beds (related to
output).
According to Indicators, Emergency Department Crowding Continues:
We found that ambulance diversions continue, wait times have increased,
and reports of boarding in hospital emergency departments persist.
Articles we reviewed also reported on the effect of crowding on quality
of care and on strategies proposed to address crowding.
Hospitals Continue to Divert Ambulances:
National data show that the diversion of ambulances continues to occur,
but that the percentage of hospitals that go on diversion and the
average number of hours hospitals spend on diversion varied by year.
According to NCHS estimates, in 2003, 45 percent of U.S. hospitals
reported going on diversion, and in 2004 through 2006, between 25 and
27 percent reported doing so. Of hospitals that reported going on
diversion, the average number of hours they reported spending on
diversion varied with an average of 276 hours in 2003 and an average of
473 hours in 2006.[Footnote 20] (See table 3.) NCHS officials provided
the percentage of missing diversion data for each year, which ranged
from 3.75 percent in 2003 to 29.1 percent in 2005.[Footnote 21] NCHS
officials, however, were unable to provide an explanation for the
variation of the percentage of hospitals going on diversion in the
United States and average hours U.S. hospitals reported spending on
diversion for these years. NCHS reported that hospitals in metropolitan
areas spent more time on diversion than hospitals in nonmetroplitan
areas in 2003 through 2004: almost half of hospitals in metropolitan
areas NCHS surveyed reported spending more than 1 percent of their
total operating time on diversion in 2003 through 2004,[Footnote 22]
compared to 1 in 10 hospitals in nonmetropolitan areas.[Footnote 23]
Some hospitals, however, reported that their state or local laws
prohibit diversion.[Footnote 24]
Table 3: Percentage of Hospitals That Reported Going on Diversion, and
Average Hours Hospitals Spent on Diversion in 2003 through 2006:
Percentage of hospitals that reported going on diversion[A]:
2003: 44.5;
2004: 24.8;
2005: 26.1;
2006: 27.3.
Average hours spent on diversion[B]:
2003: 276;
2004: 516;
2005: 323;
2006: 473.
Source: GAO analysis of NCHS data.
Notes: All estimates in this table are nationally representative.
[A] Diversion data were missing for 3.75 percent of emergency
departments in 2003, for 24.1 percent in 2004, for 29.1 percent in
2005, and for 20.5 percent in 2006.
[B] Average is the estimated mean. Standard error is a statistic used
to calculate the range of values that express the possible difference
between the sample estimate and the actual population value. The
standard error for average hours spent on diversion was 42 for 2003, 70
for 2004, 58 for 2005, and 73 for 2006.
[End of table]
Other articles that reported on results from surveys also indicated
that diversion has continued to occur in some hospitals. In 2006 and
2007, the American Hospital Association conducted surveys of community
hospital chief executive officers that asked how much time hospitals
spent on diversion in the previous year.[Footnote 25] The results from
these surveys show that some hospitals reported going on diversion.
[Footnote 26] In both American Hospital Association surveys, urban
hospitals more often reported diversion hours than rural hospitals. For
example, among hospitals responding to the 2006 American Hospital
Association survey, about 64 percent of respondents from urban
hospitals reported going on diversion, compared to about 17 percent of
respondents from rural hospitals. In addition, articles reporting on
emergency department crowding in California[Footnote 27] and Maryland
[Footnote 28] also found that diversion continues to occur and that the
time hospitals spent on diversion varied.[Footnote 29]
Wait Times Have Increased and in Some Cases Exceeded Recommended Time
Frames:
National data from NCHS indicate that wait times in the emergency
department have increased and in some cases exceeded recommended time
frames. For example, the average wait time to see a physician increased
from 46 minutes in 2003 to 56 minutes in 2006.[Footnote 30] Average
wait times also increased for patients in some acuity levels.[Footnote
31] (See figure 4.) For emergent patients,[Footnote 32] the average
wait time to see a physician increased from 23 minutes to 37 minutes,
more than twice as long as recommended for their level of acuity. For
immediate, emergent, urgent, and semiurgent patients, NCHS estimates
show that some patients were not seen within the recommended time
frames for their acuity level.
Figure 4: Average Wait Time to See a Physician, and Percentage of
Visits in Which Wait Time to See a Physician Exceeded Recommended Time
Frames by Acuity Level in 2003 and 2006:
[Refer to PDF for image: table]
Acuity level[A] (recommended time frame): Immediate[D] (less than 1
minute);
Average wait time in minutes[B], 2003: 23;
Average wait time in minutes[B], 2006: 28;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2003: 37.5;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2006: 73.9.
Acuity level[A] (recommended time frame): Emergent[D,E] (1 to 14
minutes);
Average wait time in minutes[B], 2003: 23;
Average wait time in minutes[B], 2006: 37;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2003: 37.5;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2006: 50.4.
Acuity level[A] (recommended time frame): Urgent[E] (15 to 60 minutes);
Average wait time in minutes[B], 2003: 42;
Average wait time in minutes[B], 2006: 50;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2003: 17.0;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2006: 20.7.
Acuity level[A] (recommended time frame): Semiurgent[E] (greater than 1
hour to 2 hours);
Average wait time in minutes[B], 2003: 60;
Average wait time in minutes[B], 2006: 68;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2003: 9.6;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2006: 13.3.
Acuity level[A] (recommended time frame): Nonurgent (greater than 2
hours to 24 hours);
Average wait time in minutes[B], 2003: 69;
Average wait time in minutes[B], 2006: 76;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2003: [F];
Percentage of visits in which wait time exceeded recommended time
frames[C], 2006: [F].
Acuity level[A] (recommended time frame): No triage[G,H];
Average wait time in minutes[B], 2003: 48;
Average wait time in minutes[B], 2006: 45;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2003: [I];
Percentage of visits in which wait time exceeded recommended time
frames[C], 2006: [I].
Acuity level[A] (recommended time frame): Unknown[H];
Average wait time in minutes[B], 2003: 48;
Average wait time in minutes[B], 2006: 66;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2003: [I];
Percentage of visits in which wait time exceeded recommended time
frames[C], 2006: [I].
Acuity level[A] (recommended time frame): All acuity levels;
Average wait time in minutes[B], 2003: 46;
Average wait time in minutes[B], 2006: 56;
Percentage of visits in which wait time exceeded recommended time
frames[C], 2003: [I];
Percentage of visits in which wait time exceeded recommended time
frames[C], 2006: [I].
Source: GAO analysis of NCHS data.
Notes: All estimates in this figure are nationally representative.
[A] NCHS developed time-based acuity levels based on a five-level
emergency severity index recommended by the Emergency Nurses
Association. The acuity levels describe the recommended amount of time
a patient should wait to be seen by a physician.
[B] Average is the estimated mean. Standard error is a statistic used
to calculate the range of values that express the possible difference
between the sample estimate and the actual population value. The
standard error for average wait time to see a physician in 2003 ranged
from 2 to 5 minutes. The standard error for average wait time to see a
physician in 2006 ranged from 2 to 6 minutes with the exception of a
standard error of 11 minutes for unknown acuity level.
[C] The numbers in these columns represent the percentage of visits
with wait times exceeding the recommended amount of time for their
acuity level.
[D] NCHS added an immediate wait time category to the NHAMCS survey
instrument starting in 2005. For 2003, the emergent category was
defined as a visit with a recommended wait time of less than 15
minutes.
[E] According to NCHS, from 2003 to 2006 the increase in average wait
time to see a physician for visits by emergent, urgent, and semiurgent
patients was statistically significant.
[F] For 2003, wait times in excess of 24 hours were not able to be
reported on the NHAMCS survey instrument. For 2006, no emergency
departments in the sample reported visits with wait times in excess of
24 hours. As a result, the percentages of nonurgent visits with wait
times exceeding the recommended time frame were not available.
[G] A visit in which there is no mention of an acuity rating or triage
level in the medical record, the hospital did not perform triage, or
the patient was dead on arrival.
[H] For 2003, the NHAMCS survey instrument grouped no triage and
unknown acuity level into a single category.
[I] Visits with no triage reported or an unknown acuity level did not
have an associated recommended amount of time to see a physician.
Therefore, percentages of visits with wait times exceeding recommended
time frames could not be calculated for these categories of visits, or
all acuity levels combined.
[End of figure]
The average wait time to see a physician increased in emergency
departments in metropolitan areas, and wait times were longer in
emergency departments in metropolitan areas than in nonmetropolitan
areas in 2006. In metropolitan-area emergency departments, the average
wait time to see a physician increased from 51 minutes in 2003 to 60
minutes in 2006. In nonmetropolitan-area emergency departments, the
average wait time to see a physician was estimated to be about 26
minutes in 2003 and 33 minutes in 2006.[Footnote 33] According to NCHS
data, the average length of stay in the emergency department and the
percentage of visits in which patients left before a medical evaluation
also increased. (See table 4.) See appendix IV for additional
information about wait times in the emergency department.
Table 4: Average Length of Stay in the Emergency Department, in
Minutes, and Percentage of Visits in Which Patients Left before a
Medical Evaluation in 2001 and 2006:
Average length of stay in the emergency department, in minutes: All
hospitals;
2001[A]: 178;
2006[B]: 199.
Average length of stay in the emergency department, in minutes:
Hospitals in metropolitan areas[C];
2001[A]: 189;
2006[B]: 211.
Average length of stay in the emergency department, in minutes:
Hospitals in nonmetropolitan areas[C];
2001[A]: 131;
2006[B]: 139.
Percentage of visits in which patients left before a medical
evaluation[D]: All hospitals;
2001[A]: 1.5;
2006[B]: 2.0.
Percentage of visits in which patients left before a medical
evaluation[D]: Hospitals in metropolitan areas[C];
2001[A]: 1.7;
2006[B]: 2.2.
Percentage of visits in which patients left before a medical
evaluation[D]: Hospitals in nonmetropolitan areas[C];
2001[A]: 0.6;
2006[B]: 0.9.
Source: GAO analysis of NCHS data.
Notes: All estimates in this table are nationally representative.
[A] Standard error is a statistic used to calculate the range of values
that express the possible difference between the sample estimate and
the actual population value. The standard error for the average length
of stay in the emergency department in 2001 ranged from 4 to 5 minutes.
[B] The standard error for the average length of stay in the emergency
department in 2006 ranged from 5 to 7 minutes.
[C] Metropolitan describes hospitals identified by NCHS as located in a
metropolitan statistical area and nonmetropolitan describes hospitals
identified by NCHS as not located in a metropolitan statistical area.
[D] NCHS defines the percentage of visits in which patients left before
a medical evaluation as the percentage of visits in which the patient
left after triage but before receiving any medical care.
[End of table]
Boarding Continues to Be Reported, but National Data on Boarding Have
Been Limited:
More than 25 percent of the 197 articles we reviewed discuss the
practice of boarding patients in emergency departments, and officials
we interviewed noted that the practice of boarding continues. For
example, in 2006 IOM reported that boarding continues to occur and has
become a typical practice in hospitals nationwide, with the most
boarding occurring at large urban hospitals.[Footnote 34] One article
published in a peer-reviewed journal reported that it is not unusual
for critically ill patients to board in the emergency department.
[Footnote 35] In addition, officials we interviewed noted that the
practice of boarding patients in emergency departments persists. In
particular, officials from the Center for Studying Health System Change
noted that boarding still occurs in emergency departments and continues
to be one of the main indicators of emergency department crowding.
Officials from ACEP noted that boarding continues to occur in emergency
departments nationwide and remains a concern for emergency physicians
and their patients.
National data on the boarding of patients in the emergency department,
however, have been limited. In 2006, IOM reported that hospital data
systems do not adequately monitor or measure patient flow, and
therefore may be limited in their ability to capture data on boarding.
For example, few systems distinguish between when a patient is ready to
move to another location for care and when that move actually takes
place.[Footnote 36] In addition, from 2001 to 2006, NCHS did not
collect data on boarding because, according to NCHS officials, data on
boarding were not easily obtained from patient records. A question
about emergency department boarding was added to NCHS's NHAMCS
questionnaire in 2007; however, data from this survey were not
available at the time we conducted our analysis. Other articles that
reported on results of surveys conducted by professional associations
supported officials' statements that boarding has been widespread. For
example, in an article reporting on a 2005 ACEP survey of emergency
department directors with a 30 percent response rate, 996 of the 1,328
respondents reported that they boarded patients for at least 4 hours on
a daily basis and more than 200 respondents reported that they did so
for more than 10 patients per day on average.[Footnote 37]
Articles and Officials Discussed the Effect of Crowding and Strategies
for Decreasing Diversion, Wait Times, and Boarding:
Ten of the articles we reviewed and officials from ACEP and the Society
for Academic Emergency Medicine whom we interviewed raised concerns
about the adverse effect of diversion, wait times, or boarding on the
quality of patient care, but quantitative evidence of this effect has
been limited. Officials from ACEP reported that research has begun to
analyze the effect of crowding on patient quality of care, and that
anecdotal reports indicate patients are being harmed. Ten of the
articles we reviewed discussed the effect of diversion, wait times, or
boarding on quality of care. One of these articles, the 2006 IOM
report, noted that ambulance diversion could lead to catastrophic
delays in treatment for seriously ill or injured patients and that
boarding may enhance the potential for errors, delays in treatment, and
diminished quality of care.[Footnote 38] Other articles--some of which
were published in peer-reviewed journals--also discussed the effect of
crowding on the quality of patient care, including the following:
* An examination of the relationship between trauma death rates and
hospital diversion, which suggested that death rates for trauma
patients at two hospitals may be correlated with diversion at these
hospitals.[Footnote 39]
* A review of 24 hospital emergency departments that suggested when an
emergency department experienced an increase in the number of patients
leaving before a medical evaluation, fewer patients with pneumonia at
the emergency department received antibiotics within the recommended 4
hours.[Footnote 40]
* Information from a database of 90 hospitals that showed patients who
were boarded in the emergency department for more than 6 hours before
being transferred to the hospital's intensive care unit had an almost 5
percent higher in-hospital mortality rate than those who were boarded
for less than 6 hours.[Footnote 41]
* Five other articles reported potential associations between
diversion, boarding, and wait times and decreased quality of patient
care, including articles on the effect of increasing wait times for
nonurgent patients in the emergency department and delayed treatment
time for those patients who left before a medical evaluation.
While these studies support the widely held assertion that emergency
department crowding adversely affects the quality of patient care, a
2006 National Health Policy Forum[Footnote 42] report stated that the
consequences of crowded emergency departments on quality of care have
not been studied comprehensively and therefore little quantitative
evidence is available to confirm this assumption.[Footnote 43]
Officials from the Society for Academic Emergency Medicine reported
that diversion, wait times, and boarding can contribute to reduced
quality of care and worse patient outcomes. In addition, officials from
both ACEP and the Society for Academic Emergency Medicine noted that
additional studies about the effects of diversion, wait times, and
boarding on quality of care are needed.
Articles we reviewed, and officials and an expert we interviewed,
discussed a number of strategies that have been proposed, and in some
cases tested, that could decrease emergency department crowding. These
strategies relate to the three interdependent components--input,
throughput, and output--of the model of emergency department crowding
developed by researchers. While several of these strategies have been
tested, the assessment of their effects has generally been limited to
one or a few hospitals and we found no research assessing these
strategies on a state or national level. Table 5 outlines some
strategies to address emergency department crowding and, to the extent
they have been tested, the assessment of their effects on the
indicators of crowding.
Table 5: Strategies to Address Indicators of Emergency Department
Crowding:
Strategies related to emergency department input:
Strategy: Changing diversion policies for the community;
Description of strategy: Strategies related to emergency department
input: A community developed a policy that specified when and under
what conditions a hospital was allowed to go on diversion. For example,
hospital officials were required to have a process in place that
ensured all resources in the hospital were exhausted before going on
diversion;
Assessment of the strategy's effect on indicator(s) of crowding: An
analysis comparing diversion hours before and after implementation of a
new diversion policy found that this strategy reduced the hours on
diversion by 74 percent in a community of 17 hospitals.[A]
Strategy: Physician-directed ambulance destination-control program;
Description of strategy: Strategies related to emergency department
input: Emergency medical service providers were asked to call a
dedicated telephone number that was staffed by attending physicians. A
destination-control physician determined the optimal patient
destination by using patient and system variables as well as emergency
medical service providers' and patients' input;
Assessment of the strategy's effect on indicator(s) of crowding: An
analysis comparing the diversion hours with and without this program at
two hospitals found that this program reduced the hours on diversion by
41 percent at one hospital and 61 percent at the other hospital.[B]
Strategy: State policy prohibiting diversion;
Description of strategy: Strategies related to emergency department
input: State officials developed a policy that would prohibit hospitals
from going on diversion unless the hospital is inoperable under certain
conditions;
Assessment of the strategy's effect on indicator(s) of crowding:
Officials from the state of Massachusetts issued a letter stating that
hospitals would no longer be allowed to go on diversion unless the
hospital was inoperable; however, this policy was implemented in
January 2009 and the effect on diversion had not yet been analyzed.[C]
Strategies related to emergency department throughput:
Strategy: A fast-track system;
Description of strategy: Strategies related to emergency department
input: A system that allowed nonurgent patients to be treated in less
time because these patients can be seen by a medical provider other
than a physician;
Assessment of the strategy's effect on indicator(s) of crowding: An
analysis comparing wait times before and after implementation of a fast-
track system at one hospital found that this strategy reduced both the
amount of time patients waited to be seen by a physician and the number
of patients who left before a medical evaluation by 50 percent.[D]
Strategy: A point-of-care testing satellite laboratory;
Description of strategy: Strategies related to emergency department
input: A testing laboratory was set up in close proximity to the
emergency department and staffed with a research nurse and laboratory
technicians. These staff made rounds to the emergency department to
collect specimens every 15 minutes and reported results directly to
clinicians in the emergency department by telephone or by fax;
Assessment of the strategy's effect on indicator(s) of crowding: An
analysis reviewing effects of implementation of a point-of-care testing
laboratory in a large university-associated urban hospital found that
turnaround times for test results were reduced by an average of 87
percent and length of stay in the emergency department decreased for
some patients by an average of 41 minutes.[E]
Strategy: A rapid entry and accelerated care at triage process;
Description of strategy: Strategies related to emergency department
input: A hospital computer system was revised to integrate the
emergency department computer system with the computer system for the
rest of the hospital, creating a new process when entering data for
patients at triage. This process allowed staff to eliminate some of the
administrative work associated with patients entering the emergency
department;
Assessment of the strategy's effect on indicator(s) of crowding: An
analysis comparing wait times before and after initiation of this
process at one hospital found the process significantly decreased both
the rate of patients leaving before being seen and average wait times.
The rate of patients leaving before being seen decreased by 3.3 percent
and the average wait time decreased by 24 minutes.[F]
Strategy: Bedside registration;
Description of strategy: Strategies related to emergency department
input: During times when emergency department rooms or beds were
available, patients were transported immediately after triage to a
patient-care area where they could be simultaneously seen by medical
staff and registered at the bedside by a registration clerk;
Assessment of the strategy's effect on indicator(s) of crowding: An
analysis of treatment time before and after implementation of bedside
registration at one hospital found a small, significant decrease of 13
minutes for treatment time after bedside registration was implemented.
However, this decrease did not last and treatment time even increased a
year after bedside registration was implemented at this hospital.[G]
Strategies related to emergency department output:
Strategy: Increase the capacity of the adult intensive care unit;
Description of strategy: Strategies related to emergency department
input: A hospital expanded the number of beds in its adult intensive
care unit from 47 to 67 beds;
Assessment of the strategy's effect on indicator(s) of crowding: An
analysis comparing diversion hours before and after the number of adult
intensive care unit beds had increased at one hospital found that hours
on diversion decreased by 66 percent.[H]
Strategy: Boarding in the inpatient hallways;
Description of strategy: Strategies related to emergency department
input: A system for moving nonurgent patients admitted to the hospital
to inpatient hallways instead of boarding them in emergency department
hallways;
Assessment of the strategy's effect on indicator(s) of crowding: Not
analyzed in published articles[I,J]
Strategy: A pull system in the hospital;
Description of strategy: Strategies related to emergency department
input: Staff on inpatient floors played an active role in placing
emergency department patients into available beds;
Assessment of the strategy's effect on indicator(s) of crowding: Not
analyzed in published articles[J,K]
Strategy: Streamlining of elective surgery schedules;
Description of strategy: Strategies related to emergency department
input: The strategy will streamline elective surgery schedules to make
elective daily admission volume even, and increase the opportunity for
emergency department admissions;
Assessment of the strategy's effect on indicator(s) of crowding: Case
studies were conducted at several hospitals to determine the influence
of reducing the variability of elective surgical scheduling. In one
hospital, waiting times for emergent and urgent surgeries has been
reduced by about 33 percent despite a 30 percent increase in their
volumes.[L]
Source: GAO analysis of articles published between January 1, 2003, and
August 31, 2008, and interviews.
[A] P. B. Patel et al., "Ambulance Diversion Reduction: the Sacramento
Solution," American Journal of Emergency Medicine, vol. 24, no. 2
(2006).
[B] M. N. Shah et al., "Description and Evaluation of a Pilot Physician-
directed Emergency Medical Services Diversion Control Program,"
Academic Emergency Medicine, vol. 13, no. 1 (2006).
[C] The Commonwealth of Massachusetts, Executive Office of Health and
Human Services, Department of Public Health, Circular Letter: DHCQ 08-
07-494 (Boston, Mass., July 3, 2008).
[D] M. Sanchez et al., "Effects of a Fast-Track Area on Emergency
Department Performance," The Journal of Emergency Medicine, vol. 31,
no. 1 (2006).
[E] E. Lee-Lewandrowski et al., "Implementation of a Point-of-Care
Satellite Laboratory in the Emergency Department of an Academic Medical
Center Impact on Test Turnaround Time and Patient Emergency Department
Length of Stay," Archives of Pathology & Laboratory Medicine, vol. 127,
no. 4 (2003).
[F] T. C. Chan et al., "Impact of Rapid Entry and Accelerated Care at
Triage on Reducing Emergency Department Patient Wait Times, Lengths of
Stay, and Rate of Left Without Being Seen," Annals of Emergency
Medicine, vol. 46, no. 6 (2005).
[G] K. M. Takakuwa, F. S. Shofer, and S. B. Abbuhl, "Strategies for
Dealing with Emergency Department Overcrowding: A One-Year Study on How
Bedside Registration Affects Patient Throughput Times," The Journal of
Emergency Medicine, vol. 32, no. 4 (2007).
[H] K. J. McConnel et al., "Effect of Increased ICU Capacity on
Emergency Department Length of Stay and Ambulance Diversion," Annals of
Emergency Medicine, vol. 45, no. 5 (2005).
[I] C. Garson et al., "Emergency Department Patient Preferences for
Boarding Locations When Hospitals Are at Full Capacity," Annals of
Emergency Medicine, vol. 51, no. 1 (2008).
[J] While researchers have proposed this strategy to alleviate
crowding, analysis has not been published in articles we reviewed to
determine if this strategy would decrease boarding.
[K] M. Wilson and K. Nguyen, "Bursting at the Seams, Improving Patient
Flow to Help America's Emergency Departments," (Washington, D.C.:
Urgent Matters, September 2004), [hyperlink,
http://www.urgentmatters.org/reports/UM_WhitePaper_BurstingAtTheSeams.pd
f] (accessed Sept. 30, 2008).
[L] Description of strategy and assessment based on conversation with a
subject-matter expert who oversaw these efforts. Additional information
is also available on [hyperlink, http://www.bu.edu/mvp] (accessed on
Apr. 9, 2009).
[End of table]
Available Information Suggests Lack of Access to Inpatient Beds Is the
Main Factor Contributing to Crowding, and Other Factors May Also
Contribute:
Available information suggests that a lack of access to inpatient beds
is the main factor contributing to emergency department crowding.
Additionally, other factors--a lack of access to primary care, a
shortage of available on-call specialists, and difficulties
transferring, admitting, or discharging psychiatric patients--have also
been reported as contributing to crowding.
Articles and Subject-Matter Experts Have Reported a Lack of Access to
Inpatient Beds as the Main Factor Contributing to Crowding:
Of the 77 articles we reviewed that discussed factors contributing to
crowding, 45 articles reported a lack of access to inpatient beds as a
factor contributing to emergency department crowding, with 13 of these
articles[Footnote 44] reporting it was the main factor contributing to
crowding.[Footnote 45] (See table 6.) In addition, two individual
subject-matter experts we interviewed also reported a lack of access to
inpatient beds as the main factor that contributes to emergency
department crowding. When inpatient beds are not available for ill and
injured patients who require hospital admission, the emergency
department may board them, and these patients take up extra treatment
spaces and emergency department resources, leaving fewer resources
available for other patients.
Table 6: Number of Articles Reviewed That Reported Factors Contributing
to Emergency Department Crowding:
Factor: Lack of access to inpatient beds;
Number of articles reporting this factor as one of a number of factors
contributing to crowding: 45.
Factor: Lack of access to primary care;
Number of articles reporting this factor as one of a number of factors
contributing to crowding: 22.
Factor: Shortage of available on-call specialists;
Number of articles reporting this factor as one of a number of factors
contributing to crowding: 7.
Factor: Difficulty transferring, admitting, or discharging psychiatric
patients;
Number of articles reporting this factor as one of a number of factors
contributing to crowding: 3.
Factor: Other factors[A];
Number of articles reporting this factor as one of a number of factors
contributing to crowding: 15.
Factor: Total number of articles reporting factors contributing to
emergency department crowding;
Number of articles reporting this factor as one of a number of factors
contributing to crowding: 77.
Source: GAO analysis of articles published on or between January 1,
2003, and August 31, 2008.
Notes: Numbers do not sum to total because some articles reported more
than one factor.
[A] Five other factors--an aging population, increasing acuity of
patients, staff shortages, hospital processes, and financial factors--
were mentioned in 15 articles. During our interviews with officials and
individual subject-matter experts, however, there was little mentioned
about these factors and how they contribute to crowding.
[End of table]
One of the reasons that emergency departments are unable to move
admitted patients to inpatient beds may be due to competition between
emergency department admissions and scheduled hospital admissions--for
example, for elective surgical procedures--which we also reported on in
2003. This reason was reported by 9 articles we reviewed and by
officials from ACEP, the Society for Academic Emergency Medicine, the
Center for Studying Health System Change, and three individual subject-
matter experts whom we interviewed. In 2006, IOM reported that
hospitals might prefer scheduled admissions over admissions from the
emergency department because emergency department admissions are
considered to be less profitable.[Footnote 46] One reason that
admissions from the emergency department are considered to be less
profitable is because these admissions tend to be for medical
conditions, such as heart failure and pneumonia, rather than surgical
procedures, such as joint replacement surgeries and scheduled
cardiovascular procedures. Available data from AHRQ's 2006 Healthcare
Cost and Utilization Project[Footnote 47] show all 20 of the most-
prevalent diagnosis-related groups (DRG)[Footnote 48] associated with
admissions from the emergency department in 2006 were for medical
conditions rather than surgical procedures. In contrast, 7 of the 20
most-prevalent DRGs for nonemergency department admissions in 2006 were
for surgical conditions. Officials from the Society for Academic
Emergency Medicine told us that because treating surgical conditions is
considered more profitable for a hospital than treating emergency
medical conditions, hospitals had an incentive to reserve beds for
scheduled surgical admissions rather than to give them to patients
admitted from the emergency department.[Footnote 49]
Additional Factors Reported as Contributing to Crowding:
Available information suggests that other factors also contribute to
emergency department crowding including a lack of access to primary
care, a shortage of available on-call specialists, and difficulties
transferring, admitting, or discharging psychiatric patients.
Lack of Access to Primary Care:
Twenty-two articles we reviewed reported a lack of access to primary
care as a factor contributing to emergency department crowding. For
example, one of these articles reported that difficulty in receiving
care from a primary care provider was associated with an increase in
nonurgent emergency department use.[Footnote 50] Another article
described a study in New Jersey that indicated that almost one-half of
all emergency department visits within the state that did not result in
hospital admission could have been avoided with improved access to
primary care services.[Footnote 51] Additionally, officials from the
Center for Studying Health System Change and the Society for Academic
Emergency Medicine mentioned a lack of access to primary care as a
factor contributing to emergency department crowding. When patients do
not have a primary care physician, or cannot obtain an appointment with
a primary care physician, they may go to the emergency department to
seek primary care services. In addition, patients who do not have
access to primary care may defer care until their condition has
worsened, potentially increasing the emergency department resources
needed to treat the patient's condition. These situations involve
patients that could have been treated outside of the emergency
department and may add to the number of patients seeking care at the
emergency department.
Articles we reviewed provided conflicting information on the effect of
increasing numbers of uninsured patients on emergency department
crowding. Five of the 22 articles that mentioned a lack of access to
primary care as a factor also reported that increasing numbers of
uninsured patients also contributed to emergency department crowding.
For example, 1 article indicated that a reason for longer wait times at
30 California hospitals in lower-income areas was that these hospitals
treat a disproportionate number of uninsured patients who may lack
access to primary care.[Footnote 52] Two other articles we reviewed,
however, suggested that increasing numbers of uninsured patients is not
a factor contributing to crowding. For example, the Center for Studying
Health System Change reported that contrary to the popular belief that
uninsured people are the major cause of increased emergency department
use, insured Americans accounted for most of the 16 percent increase in
visits between 1996 through 1997 and 2000 through 2001.[Footnote 53] In
addition, officials from AHRQ noted that a larger proportion of
patients using the emergency department are insured than uninsured.
Shortage of Available On-Call Specialists:
Seven articles and officials from the Center for Studying Health System
Change, ACEP, the American Hospital Association, and the American
Medical Association whom we interviewed reported that a shortage of on-
call specialists available to emergency departments is a factor that
contributes to emergency department crowding. Hospitals often employ on-
call specialists, meaning specialists such as neurosurgeons or
orthopedic surgeons who only travel to the hospital or emergency
department when needed and called. When patients wait for long periods
in the emergency department for an on-call specialist who is not
immediately available--for example, busy covering other hospitals or in
surgery--these patients might not receive timely and appropriate care.
In addition, these patients may utilize treatment spaces and resources
that could be used to treat other patients, potentially crowding the
emergency department.
In 2006 IOM reported that over the preceding several years, hospitals
had found it increasingly difficult to secure specialists for their
emergency department patients.[Footnote 54] Additionally, another
article reported the results of a 2007 American Hospital Association
survey of hospital chief executive officers that asked about
maintaining on-call specialist coverage for the emergency department.
[Footnote 55] While this survey had a low response rate, it indicates
that hundreds of emergency departments reported experiencing difficulty
in maintaining on-call coverage for certain specialists. For example,
of those chief executive officers that responded to the survey (840
chief executive officers; 17 percent of those surveyed), 44 and 43
percent noted difficulty in maintaining emergency department on-call
coverage for orthopedic surgeons and neurosurgeons, respectively.
Additionally, officials from the Center for Studying Health System
Change told us that delays in obtaining specialty services may
contribute to crowding. None of the articles we reviewed, nor officials
or individual subject-matter experts we interviewed, quantitatively
assessed the relationship between the availability of on-call
specialists and emergency department crowding.
Difficulties in Transferring, Admitting, or Discharging Psychiatric
Patients:
Three articles we reviewed and officials from NCHS, ACEP, and the
Center for Studying Health System Change whom we interviewed reported
difficulties transferring, admitting, or discharging psychiatric
patients from the emergency department as a factor contributing to
emergency department crowding. One of these articles reported the
results of a national ACEP survey of emergency physicians that asked
about psychiatric patients in the emergency department.[Footnote 56] Of
the physicians responding to the survey (328 physicians; approximately
23 percent of those surveyed), about 40 percent reported that, on
average, psychiatric patients waited in the emergency department for an
inpatient bed longer than 8 hours after the decision to admit them had
been made, including about 9 percent who reported that psychiatric
patients waited more than 24 hours. Medical patients in the emergency
department--those diagnosed with nonpsychiatric conditions--generally
waited less time for an inpatient bed: 7 percent of responding
physicians reported that, on average, medical patients waited longer
than 8 hours after the decision to admit them had been made; slightly
less than 1 percent reported that the medical patients waited more than
24 hours. In addition, the survey respondents indicated psychiatric
patients waiting to be transferred or discharged added to the burden of
an already crowded emergency department and affected access for all
patients requiring care. Also, officials from NCHS said that
psychiatric patients in the emergency department are a national concern
because they are frequent visitors to the emergency department and they
may spend more than 24 hours in an emergency department.
National data from NCHS show that, in 2006, psychiatric patients
constituted a small percentage of emergency department visits but had a
longer average length of stay in the emergency department. Almost 3
percent of emergency department visits in 2006 were by patients
presenting with a complaint of a psychological or mental disorder and
these patients had an average length of stay in the emergency
department that was longer than the average length of stay for all
other visits (397 minutes, compared to 194 minutes for all other
visits).[Footnote 57] Emergency department patients with psychiatric
disorders may need to be isolated from other patients and may require
resources that are not available in many hospitals. Hospital emergency
departments often have limited or no specialized psychiatric facilities
and emergency department staff may experience difficulties transferring
such patients to other facilities, admitting them to the hospital, or
discharging them from the emergency department. Additionally, emergency
department staff may spend a disproportionate amount of time and
resources caring for psychiatric patients while these patients wait for
transfer, admission, or discharge.
Other Possible Factors That Contribute to Crowding:
Our literature review identified five other factors that may contribute
to emergency department crowding. For example, in 2006 IOM reported
these five factors--an aging population, increasing acuity of patients,
staff shortages, hospital processes, and financial factors--as possible
factors that might contribute to emergency department crowding,
[Footnote 58] and these five factors were also mentioned in 14 other
articles we reviewed. However, during our interviews with officials and
individual subject-matter experts, there was little mentioned about
these factors and how they contribute to crowding.
Agency Comments and Our Evaluation:
HHS provided comments on a draft of this report, which are included in
appendix V. In its comments, HHS noted that the report demonstrates
that emergency department wait times continue to increase and
frequently exceed national standards. HHS also commented that strengths
of the report include its clarity, focus, and tone.
In addition, HHS commented on the scope of the report and limitations
of the indicators used in it. HHS suggested that the information
provided in the report would be strengthened by inclusion of articles
published prior to 2003 and articles reporting on studies conducted
outside of the United States. We focused our literature review on
articles published since 2003 to review information made available
since we issued our 2003 report. And while articles reporting on
studies conducted outside of the United States may include valuable
information regarding aspects of emergency department crowding as it
occurs in other countries, we reviewed articles reporting on studies
conducted in the United States because our focus was on the U.S. health
care system. HHS also commented that the indicators of crowding that we
used had limitations. As we noted both in our 2003 report and in this
report, these indicators have limitations but, in the absence of a
widely accepted standard measure of crowding, they are used by
researchers to point to situations in which crowding is likely
occurring.
HHS also provided technical comments, which we incorporated as
appropriate.
As agreed with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. At that time, we will send copies of this report
to the Secretary of Health and Human Services and other interested
parties. The report will be available at no charge on GAO's Web site at
[hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or crossem@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff members who made major
contributions to this report are listed in appendix VI.
Sincerely yours,
Signed by:
Marcia Crosse:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
To examine national data made available since 2003 on emergency
department diversion and wait times, we obtained and reviewed data
collected by the National Center for Health Statistics (NCHS) through
its National Hospital Ambulatory Medical Care Survey (NHAMCS).[Footnote
59] We analyzed available NCHS data[Footnote 60] for 2001 through 2006
on diversion[Footnote 61] and wait times[Footnote 62] to determine what
changes, if any, have occurred over time. We analyzed wait time data by
patient acuity level[Footnote 63] and hospital characteristics, such as
hospital ownership,[Footnote 64] metropolitan or nonmetropolitan area
location,[Footnote 65] and geographic region.[Footnote 66] We analyzed
wait times in the emergency department using NCHS's data on recommended
time for a patient to see a physician based on patient acuity levels.
Further, to determine the average length of stay in the emergency
department for patients who presented with a psychological or mental
disorder, we analyzed emergency department length of stay by the type
of patient complaint at time of the visit. We also analyzed NCHS data
on emergency department utilization by payer source, including
Medicare, Medicaid, and the State Children's Health Insurance Program,
[Footnote 67] self pay, no charge or charity care; and by hospital
characteristics, such as whether the hospital was located in a
metropolitan or nonmetroplitan area, to provide context for our work.
We also reviewed and analyzed data from the Agency for Healthcare
Research and Quality's (AHRQ) Healthcare Cost and Utilization Project
[Footnote 68] to determine the diagnosis-related groups (DRG)[Footnote
69] most commonly associated with hospital admissions from the
emergency department and most commonly associated with non-emergency
department admissions--information we determined was related to factors
that contribute to crowding.[Footnote 70] We obtained NCHS and AHRQ
data beginning with 2001 because these data became publicly available
in 2003 or later, meeting the criterion for inclusion in our analysis.
Some data were not available from NCHS for all years between 2001 and
2006 because of revisions made by NCHS to questions on surveys used to
collect information and because of low response rates to certain
questions on these surveys. At the time we conducted our analysis, the
most recent year for which data were available from NCHS and AHRQ was
2006. In this report, we present NCHS estimates; for those cases in
which we report an increase or other comparison of these estimates,
NCHS tested the differences and found them statistically significant.
[Footnote 71] To assess the reliability of national data from NCHS and
AHRQ, we interviewed agency officials and reviewed the methods they
used for collecting and reporting these data. We resolved discrepancies
we found between the data provided to us and data in published reports
by corresponding with officials from NCHS to obtain sufficient
explanations for the differences.[Footnote 72] Based on these steps, we
determined that these data were sufficiently reliable for our purposes.
To examine information available since 2003 about three indicators of
emergency department crowding and the factors that contribute to
crowding, we conducted a literature review. In examining information
made available since 2003 about indicators and factors of crowding
during our literature review, we analyzed articles for what was
reported on the effect of crowding on patient quality of care and
proposed strategies to address crowding. We conducted a structured
search of 16 databases that included peer-reviewed journal articles and
other periodicals to capture articles published on or between January
1, 2003, and August 31, 2008. We searched these databases for articles
with key words in their title or abstract related to emergency
department crowding, or indicators and factors of crowding, such as
versions of the word "crowding," "emergency department," "diversion,"
"wait time," and "boarding." We also included articles published on or
between January 1, 2003, and August 31, 2008, that were identified as a
result of our interviews with federal officials, professional and
research organizations, and subject-matter experts. We also searched
related Web sites for additional emergency department crowding
publications, including articles reporting on surveys conducted by
professional organizations, such as the American Hospital Association.
For these articles, we identified the number of respondents and
response rates, and for those with lower response rates, we noted them
in our report. From all of these sources, we identified over 300
articles, publications and reports (which we call articles) published
from January 1, 2003, through August 31, 2008. Within the more than 300
articles, we excluded articles that were published outside of the
United States, reported on subjects or data from outside the United
States, were only available in an abstract form, had a focus other than
day-to-day emergency department operations, or were unrelated to
emergency department crowding. We supplemented the articles that were
not excluded from our search by reviewing references contained in the
bibliography of these articles for additional articles published on or
between January 1, 2003, and August 31, 2008, on emergency department
crowding that met our inclusion criteria. In total, we included 197
articles[Footnote 73] in our literature review and analyzed these
articles to summarize information on emergency department crowding,
including information on diversion, wait times, and boarding, the
effect of these indicators of crowding on quality of care, proposed
strategies to decrease these indicators, and factors that contributed
to emergency department crowding. To review a complete bibliography of
these articles, see GAO-09-348SP.
Additionally, we interviewed officials from federal agencies and one
state agency, officials from professional, research, and other hospital-
related organizations, and individual subject-matter experts to obtain
and review information on indicators of emergency department crowding
and factors that contribute to crowding. During our interviews, we
asked about the effect of crowding on patient quality of care and
proposed strategies for addressing crowding. We interviewed federal
officials from the Department of Health and Human Services' Centers for
Medicare & Medicaid Services and the Office of the Assistant Secretary
for Preparedness and Response, and officials from NCHS and AHRQ who
have conducted research on emergency department utilization and
crowding. We also interviewed officials from the Massachusetts
Department of Public Health to discuss the state's planned
implementation of a new diversion policy in January 2009. We
interviewed officials from professional organizations, including the
American College of Emergency Physicians (ACEP), the American Hospital
Association, the American Medical Association, the Emergency Nurses
Association, the National Association of EMS Physicians, and the
Society for Academic Emergency Medicine. Some officials from ACEP and
the Society for Academic Emergency Medicine have published research in
peer-reviewed journals. In addition, we interviewed officials from
research organizations, such as the California Healthcare Foundation,
the Center for Studying Health System Change,[Footnote 74] the Heritage
Foundation, and the Robert Wood Johnson Foundation's Urgent Matters. We
interviewed officials from the Joint Commission (an organization
involved in hospital accreditation), the Medicare Payment Advisory
Commission (an organization that studies Medicare payment issues and
reports to Congress), and the National Quality Forum (an organization
that develops quality measures for emergency department care). We also
interviewed three individual subject-matter experts who have conducted
research on emergency department crowding and strategies to reduce
crowding.
We conducted this performance audit from May 2008 through April 2009 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
[End of section]
Appendix II: Emergency Department Utilization, 2001 through 2006:
This appendix provides information on nationally-representative
estimates of emergency departments and emergency department visits in
the United States by characteristics such as patient acuity level,
payer source, hospital ownership type, geographic region, and type of
area (metropolitan or nonmetropolitan) from the National Center for
Health Statistics' (NCHS) National Hospital Ambulatory Medical Care
Survey (NHAMCS). Specifically, for 2001 through 2006[Footnote 75] this
appendix presents the following information:
* the percentage of emergency departments by hospital ownership type,
by geographic region, and by type of area (metropolitan or
nonmetropolitan) (table 7);
* the number and percentage of emergency department visits by acuity
level (figure 5) and payer source (table 8);
* the number and percentage of emergency department visits by hospital
ownership type, geographic region, and type of area (table 9); and:
* the number and percentage of emergency department visits that
resulted in hospital admissions (table 10).
Table 7: Percentage of Emergency Departments by Hospital Ownership
Type, Geographic Region, and Type of Area in 2001 through 2006:
Hospital ownership type: Voluntary, nonprofit;
2001: 62;
2002: 65;
2003: 62;
2004: 67;
2005: 68;
2006: 68.
Hospital ownership type: Government[A];
2001: 27;
2002: 22;
2003: 27;
2004: 25;
2005: 22;
2006: 22.
Hospital ownership type: Proprietary;
2001: 11;
2002: 13;
2003: 12;
2004: 8;
2005: 9;
2006: 10.
Geographic region[B]: Northeast;
2001: 15;
2002: 15;
2003: 16;
2004: 15;
2005: 15;
2006: 14.
Geographic region[B]: Midwest;
2001: 30;
2002: 29;
2003: 29;
2004: 30;
2005: 31;
2006: 29.
Geographic region[B]: South;
2001: 37;
2002: 38;
2003: 39;
2004: 37;
2005: 37;
2006: 39.
Geographic region[B]: West;
2001: 18;
2002: 18;
2003: 17;
2004: 18;
2005: 17;
2006: 19.
Type of area: Metropolitan[C];
2001: 62;
2002: 60;
2003: 58;
2004: 66;
2005: 65;
2006: 66.
Type of area: Nonmetropolitan[C];
2001: 38;
2002: 40;
2003: 42;
2004: 34;
2005: 35;
2006: 34.
Source: GAO analysis of NCHS data.
Notes: Percentages may not sum to 100 because of rounding.
[A] NCHS defines a government-owned hospital as a hospital operated by
a state, county, city, city-county, or hospital district or authority.
[B] NCHS categorizes geographic regions in the NHAMCS as Northeast,
Midwest, South, and West as defined by the U.S. Census Bureau.
[C] Metropolitan describes hospitals identified by NCHS as located in a
metropolitan statistical area, and nonmetropolitan describes hospitals
identified by NCHS as not located in a metropolitan statistical area.
[End of table]
Figure 5: Number and Percentage of Emergency Department Visits by
Acuity Level in 2001 through 2006:
Number in thousands (percentage):
[Refer to PDF for image: table]
Acuity level[A] (recommended time frame): Immediate[B] (less than 1
minute);
2001: 20,691 (19);
2002: 24,551 (22);
2003: 17,297 (15);
2004: 14,202 (13);
2005: 6,385 (6);
2006: 6,084 (5).
Acuity level[A] (recommended time frame): Emergent[B] (1 to 14
minutes);
2001: 20,691 (19);
2002: 24,551 (22);
2003: 17,297 (15);
2004: 14,202 (13);
2005: 11,313 (10);
2006: 12,817 (11).
Acuity level[A] (recommended time frame): Urgent (15 to 60 minutes);
2001: 34,057 (32);
2002: 37,639 (34);
2003: 40,128 (35);
2004: 41,624 (38);
2005: 38,433 (33);
2006: 43,666 (37).
Acuity level[A] (recommended time frame): Semiurgent (greater than 1
hour to 2 hours);
2001: 17,543 (16);
2002: 20,427 (19);
2003: 22,830 (20);
2004: 24,012 (22);
2005: 23,870 (21);
2006: 26,173 (22).
Acuity level[A] (recommended time frame): Nonurgent (greater than 2
hours to 24 hours);
2001: 9,790 (9);
2002: 11,209 (10);
2003: 14,571 (13);
2004: 13,774 (13);
2005: 16,068 (14);
2006: 14,478 (12).
Acuity level[A] (recommended time frame): No triage[C,D];
2001: 25,409 (24);
2002: 16,328 (15);
2003: 19,077 (17);
2004: 16,605 (15);
2005: 2,397 (2);
2006: 1,860 (2).
Acuity level[A] (recommended time frame): Unknown[D];
2001: 25,409 (24);
2002: 16,328 (15);
2003: 19,077 (17);
2004: 16,605 (15);
2005: 16,857 (15);
2006: 14,114 (12).
Notes: Percentages may not sum to 100 because of rounding.
[A] NCHS developed time-based acuity levels based on a five-level
severity index recommended by the Emergency Nurses Association. The
acuity levels describe the recommended amount of time a patient should
wait to be seen by a physician.
[B] NCHS added an immediate wait time category to the NHAMCS survey
starting in 2005. For 2001 through 2004, the emergent category was
defined as a visit with a recommended wait time of less than 15
minutes.
[C] A visit in which there is no mention of an acuity rating or triage
level in the medical record, the hospital did not perform triage, or
the patient was dead on arrival.
[D] For 2001 through 2004, the NHAMCS survey instrument grouped no
triage and unknown triage level into a single category.
[End of figure]
Table 8: Number and Percentage of Emergency Department Visits by Payer
Source in 2001 through 2006:
Number in thousands (percentage):
Payer source[A]: Private insurance;
2001: 43,213 (40);
2002: 42,802 (39);
2003: 41,461 (36);
2004: 39,344(36);
2005: 39,565 (34);
2006: 40,037 (34).
Payer source[A]: Medicare;
2001: 15,879 (15);
2002: 16,964 (15);
2003: 18,525 (16);
2004: 16,909 (15);
2005: 16,043 (14);
2006: 16,780 (14).
Payer source[A]: Medicaid/State Children's Health Insurance Program;
2001: 18,789 (18);
2002: 21,751 (20);
2003: 24,415 (21);
2004: 24,489 (22);
2005: 28,661 (25);
2006: 30,351 (26).
Payer source[A]: Worker's compensation;
2001: 2,665 (3);
2002: 2,148 (2);
2003: 2,130 (2);
2004: 1,964 (2);
2005: 1,941 (2);
2006: 2,045 (2).
Payer source[A]: Self-pay[B];
2001: 15,854 (15);
2002: 15,935 (14);
2003: 16,066 (14);
2004: 17,669 (16);
2005: 18,581 (16);
2006: 19,260 (16).
Payer source[A]: No charge/Charity[B];
2001: 1,042 (1);
2002: 1,155 (1);
2003: 1,113 (1);
2004: 885 (1);
2005: 885 (1);
2006: 1,756 (1).
Payer source[A]: Other;
2001: 2,327 (2);
2002: 2,551 (2);
2003: 2,800 (2);
2004: 3,081 (3);
2005: 2,184 (2);
2006: 3,311 (3).
Payer source[A]: Unknown;
2001: 6,024 (6);
2002: 5,266 (5);
2003: 6,014 (5);
2004: 4,946 (4);
2005: 5,996 (5);
2006: 4,314 (4).
Payer source[A]: Blank;
2001: 1,697 (2);
2002: 1,582 (1);
2003: 1,377 (1);
2004: 930 (1);
2005: 1,466 (1);
2006: 1,337 (1).
Source: GAO analysis of NCHS data.
Notes: Percentages may not sum to 100 because of rounding.
[A] In 2001 through 2004, the survey asked for primary expected source
of payment. In 2005 and 2006, multiple sources could be reported. For
the purposes of comparability, in this table, 2005 and 2006 data were
recoded to produce a primary expected source of payment based on this
hierarchy of responses: Medicare, Medicaid, private insurance, worker's
compensation, self-pay, no charge, other, and unknown.
[B] NCHS defines no insurance as having only self-pay, no charge, or
charity as payment sources.
[End of table]
Table 9: Number and Percentage of Emergency Department Visits by
Hospital Ownership Type, Geographic Region, and Type of Area in 2001
through 2006:
Number in thousands (percentage):
Hospital ownership type: Voluntary, nonprofit;
2001: 78,458 (73);
2002: 76,869 (70);
2003: 82,170 (72);
2004: 82,117 (75);
2005: 83,288 (72);
2006: 86,731 (73).
Hospital ownership type: Government[A];
2001: 18,663 (17);
2002: 20,279 (18);
2003: 21,116 (19);
2004: 18,832 (17);
2005: 19,576 (17);
2006: 20,882 (18).
Hospital ownership type: Proprietary;
2001: 10,370 (10);
2002: 13,007 (12);
2003: 10,617 (9);
2004: 9,267 (8);
2005: 12,459 (11);
2006: 11,578 (10).
Geographic region[B]: Northeast;
2001: 20,802 (19);
2002: 18,895 (17);
2003: 23,814 (21);
2004: 22,274 (20);
2005: 22,245 (19);
2006: 22,669 (19).
Geographic region[B]: Midwest;
2001: 26,688 (25);
2002: 26,006 (24);
2003: 25,205 (22);
2004: 26,806 (24);
2005: 28,771 (25);
2006: 25,735 (22).
Geographic region[B]: South;
2001: 40,512 (38);
2002: 45,544 (41);
2003: 44,958 (40);
2004: 41,150 (37);
2005: 43,871 (38);
2006: 50,642 (43).
Geographic region[B]: West;
2001: 19,489 (18);
2002: 19,710 (18);
2003: 19,926 (18);
2004: 19,986 (18);
2005: 20,436 (18);
2006: 20,145 (17).
Type of area: Metropolitan[C];
2001: 88,605 (82);
2002: 89,170 (81);
2003: 92,847 (82);
2004: 94,826 (86);
2005: 98,622 (86);
2006: 100,727 (85).
Type of area: Nonmetropolitan[C];
2001: 18,885 (18);
2002: 20,985 (19);
2003: 21,056 (19);
2004: 15,391 (14);
2005: 16,700 (15);
2006: 18,464 (16).
Source: GAO analysis of NCHS data.
Notes: Percentages may not sum to 100 because of rounding.
[A] NCHS defines a government-owned hospital as a hospital operated by
a state, county, city, city-county, or hospital district or authority.
[B] NCHS categorizes geographic regions in the NHAMCS as Northeast,
Midwest, South, and West as defined by the U.S. Census Bureau.
[C] Metropolitan describes hospitals identified by NCHS as located in a
metropolitan statistical area, and nonmetropolitan describes hospitals
identified by NCHS as not located in a metropolitan statistical area.
[End of table]
Table 10: Number and Percentage of Emergency Department Visits That
Resulted in Hospital Admissions in 2001 through 2006 (In thousands):
Number of emergency department visits resulting in hospital admissions:
2001: 12,626;
2002: 13,471;
2003: 15,809;
2004: 14,615;
2005: 13,867;
2006: 15,210.
Percentage of all emergency department visits resulting in hospital
admissions:
2001: 11.7;
2002: 12.2;
2003: 13.9;
2004: 13.3;
2005: 12.0;
2006: 12.8.
Source: GAO analysis of NCHS data.
[End of table]
[End of section]
Appendix III: Proposed Measures of Emergency Department Crowding:
Researchers continue to use diversion, wait times (including patients
who left before a medical evaluation), and boarding as indicators to
point to situations in which crowding is likely occurring in emergency
departments; however, as we reported in our 2003 report, there is no
standard measure of the extent to which emergency departments are
experiencing crowding. In the absence of a widely-accepted standard
measure of crowding, researchers have proposed and conducted limited
testing of potential measures of crowding. During our literature review
of articles on emergency department crowding published on or between
January 1, 2003, and August 31, 2008, we identified proposed measures
of crowding that researchers have tested, either in a single hospital
setting or for a limited period of time. Table 11 describes these
proposed measures. While researchers have claimed varying levels of
success using these measures to gauge crowding, we found no widely
accepted measure of emergency department crowding, and that none of
these measures of crowding had been widely implemented by researchers
and health care practitioners.
Table 11: Proposed Measures of Emergency Department Crowding:
Measure: Emergency department occupancy rate;
Description: The total number of patients in the emergency department
divided by the total number of licensed emergency department treatment
bays available per hour;
Scale: An emergency department occupancy rate above 1.0 indicates that
there are more patients in the emergency department than treatment
bays. The higher the emergency department occupancy rate, the more
crowded the emergency department.[A]
Measure: Emergency department work index, also known as EDWIN;
Description: A summary statistic that describes the ratio of patients
in the emergency department at each triage level compared to the number
of attending physicians and unoccupied beds in the emergency
department;
Scale: Higher EDWIN scores are associated with more crowding in the
emergency department, greater acuity among emergency department
patients, or both.[B]
Measure: Emergency department work score;
Description: A composite score that measures where emergency
departments utilize resources. The emergency department work score
incorporates the number of patients in the waiting room, workload per
nurse for patients under evaluation in the emergency department, and
the number of patients boarding in the emergency department;
Scale: Increases in the emergency department work score indicate an
increased probability that an emergency department will go on
diversion.[C]
Measure: National emergency department overcrowding study, also known
as NEDOCS;
Description: A screening tool used to determine the degree of emergency
department crowding at an academic institution. NEDOCS incorporates the
number of patients in the emergency department, wait times, staffing in
the emergency department, and emergency department hours on diversion;
Scale: The NEDOCS score is measured on a scale between 0 and 200.
Scores over 100 reflect a progressively more crowded emergency
department.[D]
Measure: Real-time emergency analysis of demand indicators, also known
as READI;
Description: A measure used to predict emergency department demand. The
READI analysis evaluates treatment space availability, the acuity of
emergency department patients, the productivity of physicians, and an
overall measure of demand. The READI analysis uses a bed ratio, an
acuity ratio, and a provider ratio to create a demand value score;
Scale: Demand value scores greater than 7 should alert the staff to
look at each specific ratio to determine possible contributors to
demand in excess of emergency department capacity.[E]
Measure: Emergency department crowding scale;
Description: The scale is used to provide an objective measure of
emergency department crowding based on a small set of easily accessible
factors. These factors include the number of attending emergency
physicians, number of staffed emergency department beds, number of
critical-care patients, total number of emergency department patients,
number of staffed hospital beds, and hospital occupancy rate;
Scale: An emergency department crowding scale score greater than 65 may
be predictive of both ambulance diversion and the number of patients
who leave without being seen by a physician.[F]
Source: GAO analysis of articles published between January 1, 2003, and
August 31, 2008.
[A] M. L. McCarthy, et al., "The Emergency Department Occupancy Rate: A
Simple Measure of Emergency Department Crowding?" Annals of Emergency
Medicine, vol. 51, no. 1 (2008).
[B] S. L. Bernstein, et al., "Development and Validation of a New Index
to Measure Emergency Department Crowding," Academic Emergency Medicine,
vol. 10, no. 9 (2003).
[C] S. Epstein and L. Tian, "Development of an Emergency Department
Work Score to Predict Ambulance Diversion," Academic Emergency
Medicine, vol. 13, no. 4 (2006).
[D] S. Weiss, et al., "Estimating the Degree of Emergency Department
Overcrowding in Academic Medical Centers: Results of the National ED
Overcrowding Study (NEDOCS)," Academic Emergency Medicine, vol. 11, no.
1 (2004).
[E] T. Reeder, et. al., "The Overcrowded Emergency Department: A
Comparison of Staff Perceptions," Academic Emergency Medicine, vol. 10,
no. 10 (2003).
[F] S. Jones, et al., "An Independent Evaluation of Four Quantitative
Emergency Department Crowding Scales," Academic Emergency Medicine,
vol. 13, no. 11 (2006).
[End of table]
[End of section]
Appendix IV: Emergency Department Wait Times:
This appendix provides information on nationally-representative
estimates of intervals of emergency department wait times in the United
States: wait time to see a physician, length of stay in the emergency
department, and the percentage of visits in which patients left before
a medical evaluation.[Footnote 76] Specifically, this appendix presents
the following information from the National Center for Health
Statistics' (NCHS) National Hospital Ambulatory Medical Care Survey
(NHAMCS):
* for 2003 through 2006 (the only years for which data were available
from NCHS), the percentage of emergency department visits by wait time
to see a physician (table 12), average and median wait times to see a
physician by patient acuity level (figure 6), average wait times to see
a physician by payer type, hospital type, and geographic region (table
13), and average wait times by the hospitals' percentage of visits in
which patients left before a medical evaluation (table 14); and:
* for 2001 through 2006, the percentage of visits by emergency
department length of stay (table 15), the average and median length of
stay by patient acuity level (figure 7), the average length of stay in
the emergency department by payer type, hospital type, and geographic
region (table 16); and average length of stay by the hospitals'
percentage of visits in which patients left before a medical evaluation
(table 17).
Table 12: Percentage of Emergency Department Visits by Wait Time to See
a Physician, in 2003 through 2006:
Wait time to see a physician: Less than 15 minutes;
2003: 23.4;
2004: 21.5;
2005: 22.2;
2006: 21.9.
Wait time to see a physician: 15 to 59 minutes;
2003: 39.2;
2004: 42.3;
2005: 41.0;
2006: 39.9.
Wait time to see a physician: 1 hour or more, but fewer than 2 hours;
2003: 13.3;
2004: 14.3;
2005: 15.4;
2006: 14.8.
Wait time to see a physician: 2 hours or more, but fewer than 3 hours;
2003: 4.3;
2004: 4.4;
2005: 5.2;
2006: 5.5.
Wait time to see a physician: 3 hours or more, but fewer than 4 hours;
2003: 1.6;
2004: 1.8;
2005: 2.3;
2006: 2.2.
Wait time to see a physician: 4 hours or more, but fewer than 6 hours;
2003: 1.4;
2004: 1.2;
2005: 1.4;
2006: 1.4.
Wait time to see a physician: 6 hours or more;
2003: 0.1;
2004: 0.1;
2005: 1.1;
2006: 0.9.
Wait time to see a physician: Blank;
2003: 16.7;
2004: 14.4;
2005: 11.4;
2006: 13.5.
Source: GAO analysis of NCHS data.
Note: Percentages may not sum to 100 because of rounding.
[End of table]
Figure 6: Average and Median Wait Time to See a Physician, in Minutes,
by Acuity Level, in 2003 through 2006:
[Refer to PDF for image: table]
Acuity level[A] (recommended time frame): Immediate[C] (less than 1
minute):
2003, Avg (SE)[B]: 23 (2);
2003 Median: 12;
2004, Avg (SE)[B]: 26 (2);
2004 Median: 13;
2005, Avg (SE)[B]: 30 (4);
2005 Median: 10;
2006, Avg (SE)[B]: 28 (3);
2006 Median: 11.
Acuity level[A] (recommended time frame): Emergent[C] (1 to 14
minutes):
2003, Avg (SE)[B]: 23 (2);
2003 Median: 12;
2004, Avg (SE)[B]: 26 (2);
2004 Median: 13;
2005, Avg (SE)[B]: 36 (3);
2005 Median: 15;
2006, Avg (SE)[B]: 37 (3);
2006 Median: 17.
Acuity level[A] (recommended time frame): Urgent (15 to 60 minutes):
2003, Avg (SE)[B]: 42 (2);
2003 Median: 26;
2004, Avg (SE)[B]: 43 (2);
2004 Median: 28;
2005, Avg (SE)[B]: 55 (2);
2005 Median: 32;
2006, Avg (SE)[B]: 50 (2);
2006 Median: 30.
Acuity level[A] (recommended time frame): Semiurgent (greater than 1
hour to 2 hours):
2003, Avg (SE)[B]: 60 (2);
2003 Median: 42;
2004, Avg (SE)[B]: 60 (2);
2004 Median: 41;
2005, Avg (SE)[B]: 69 (3);
2005 Median: 45;
2006, Avg (SE)[B]: 68 (3);
2006 Median: 45.
Acuity level[A] (recommended time frame): Nonurgent (greater than 2
hours to 24 hours):
2003, Avg (SE)[B]: 69 (5);
2003 Median: 44;
2004, Avg (SE)[B]: 65 (3);
2004 Median: 42;
2005, Avg (SE)[B]: 66 (3);
2005 Median: 41;
2006, Avg (SE)[B]: 76 (6);
2006 Median: 44.
Acuity level[A] (recommended time frame): No triage[D,E]:
2003, Avg (SE)[B]: 48 (5);
2003 Median: 25;
2004, Avg (SE)[B]: 49 (4);
2004 Median: 28;
2005, Avg (SE)[B]: 31 (7);
2005 Median: 15;
2006, Avg (SE)[B]: 45 (6);
2006 Median: 22.
Acuity level[A] (recommended time frame): Unknown[E]:
2003, Avg (SE)[B]: 48 (5);
2003 Median: 25;
2004, Avg (SE)[B]: 49 (4);
2004 Median: 28;
2005, Avg (SE)[B]: 63 (7);
2005 Median: 27;
2006, Avg (SE)[B]: 66 (11);
2006 Median: 30.
Acuity level[A] (recommended time frame): All Acuity Levels:
2003, Avg (SE)[B]: 46 (2);
2003 Median: 27;
2004, Avg (SE)[B]: 47 (1);
2004 Median: 29;
2005, Avg (SE)[B]: 56 (2);
2005 Median: 31;
2006, Avg (SE)[B]: 56 (2);
2006 Median: 31.
Source: GAO analysis of NCHS data.
[A] NCHS developed time-based acuity levels based on a five-level
severity index recommended by the Emergency Nurses Association. The
acuity levels describe the recommended amount of time a patient should
wait to be seen by a physician.
[B] Avg is the estimated mean and SE is the standard error of the
estimate. Standard error is a statistic used to calculate the range of
values that express the possible difference between the sample estimate
and the actual population value.
[C] NCHS added an immediate wait time category to the NHAMCS survey
instrument starting in 2005. For 2003 and 2004, the emergent category
was defined as any visit with a recommended wait time of less than 15
minutes.
[D] No triage indicates a visit in which there is no mention of an
acuity rating or triage level in the medical record, the hospital did
not perform triage, or the patient was dead on arrival.
[E] For 2003 and 2004, the NHAMCS survey instrument grouped no triage
and unknown triage level into a single category.
[End of figure]
Table 13: Average Wait Time to See a Physician, in Minutes, by Payer
Type, Hospital Type, and Geographic Region, in 2003 through 2006:
Average wait time to see a physician by payer type[B]: Private
insurance;
2003 (SE)[A]: 45 (2);
2004 (SE)[A]: 46 (1);
2005 (SE)[A]: 55 (2);
2006 (SE)[A]: 55 (3).
Average wait time to see a physician by payer type[B]: Medicare; 2003
(SE)[A]: 40 (2);
2004 (SE)[A]: 43 (1);
2005 (SE)[A]: 52 (3);
2006 (SE)[A]: 52 (3).
Average wait time to see a physician by payer type[B]: Medicaid/State
Children's Health Insurance Program;
2003 (SE)[A]: 49 (2);
2004 (SE)[A]: 50 (2);
2005 (SE)[A]: 59 (2);
2006 (SE)[A]: 56 (2).
Average wait time to see a physician by payer type[B]: Worker's
compensation;
2003 (SE)[A]: 37 (3);
2004 (SE)[A]: 46 (2);
2005 (SE)[A]: 39 (3);
2006 (SE)[A]: 41 (3).
Average wait time to see a physician by payer type[B]: Self-pay;
2003 (SE)[A]: 50 (2);
2004 (SE)[A]: 49 (2);
2005 (SE)[A]: 57 (3);
2006 (SE)[A]: 62 (4).
Average wait time to see a physician by payer type[B]: No
charge/charity;
2003 (SE)[A]: 104 (30);
2004 (SE)[A]: 72 (8);
2005 (SE)[A]: 69 (7);
2006 (SE)[A]: 81 (15).
Average wait time to see a physician by payer type[B]: Other;
2003 (SE)[A]: 52 (6);
2004 (SE)[A]: 48 (5);
2005 (SE)[A]: 58 (4);
2006 (SE)[A]: 48 (6).
Average wait time to see a physician by payer type[B]: Unknown or
blank;
2003 (SE)[A]: 48 (3);
2004 (SE)[A]: 56 (4);
2005 (SE)[A]: 64 (3);
2006 (SE)[A]: 57 (5).
Average wait time to see a physician by hospital type: Voluntary,
nonprofit;
2003 (SE)[A]: 46 (2);
2004 (SE)[A]: 47 (2);
2005 (SE)[A]: 57 (2);
2006 (SE)[A]: 55 (2).
Average wait time to see a physician by hospital type: Government[C];
2003 (SE)[A]: 51 (6);
2004 (SE)[A]: 50 (4);
2005 (SE)[A]: 51 (4);
2006 (SE)[A]: 59 (7).
Average wait time to see a physician by hospital type: Proprietary;
2003 (SE)[A]: 42 (5);
2004 (SE)[A]: 45 (3);
2005 (SE)[A]: 57 (7);
2006 (SE)[A]: 58 (11).
Average wait time to see a physician by geographic region[D]:
Northeast;
2003 (SE)[A]: 48 (3);
2004 (SE)[A]: 51 (3);
2005 (SE)[A]: 57 (4);
2006 (SE)[A]: 56 (3).
Average wait time to see a physician by geographic region[D]: Midwest;
2003 (SE)[A]: 42 (2);
2004 (SE)[A]: 42 (4);
2005 (SE)[A]: 49 (3);
2006 (SE)[A]: 50 (4).
Average wait time to see a physician by geographic region[D]: South;
2003 (SE)[A]: 48 (4);
2004 (SE)[A]: 48 (2);
2005 (SE)[A]: 58 (3);
2006 (SE)[A]: 61 (4).
Average wait time to see a physician by geographic region[D]: West;
2003 (SE)[A]: 48 (5);
2004 (SE)[A]: 50 (3);
2005 (SE)[A]: 63 (6);
2006 (SE)[A]: 49 (5).
Source: GAO analysis of NCHS data.
[A] Average is the estimated mean and SE is the standard error of the
estimate. Standard error is a statistic used to calculate the range of
values that express the possible difference between the sample estimate
and the actual population value.
[B] In 2003 and 2004, the survey asked for primary expected source of
payment. In 2005 and 2006, multiple sources could be reported. For the
purposes of comparability, in this table, 2005 and 2006 data were
recoded to produce a primary expected source of payment based on this
hierarchy of responses: Medicare, Medicaid, private insurance, worker's
compensation, self-pay, no charge, other, and unknown.
[C] NCHS defines a government-owned hospital as a hospital operated by
a state, county, city, city-county, or hospital district or authority.
[D] NCHS categorizes geographic regions in the NHAMCS as Northeast,
Midwest, South, and West as defined by the U.S. Census Bureau.
[End of table]
Table 14: Average Wait Time to See a Physician, in Minutes, by
Hospitals' Percentage of Visits in Which Patients Left before a Medical
Evaluation, in 2003 through 2006:
Percentage of visits in which patients left before a medical
evaluation[A]: Less than 1 percent;
2003 Avg (SE)[B]: 30 (2);
2004 Avg (SE)[B]: 30 (1);
2005 Avg (SE)[B]: 38 (3);
2006[C] Avg (SE)[B]: 37 (3).
Percentage of visits in which patients left before a medical
evaluation[A]: 1 percent to 2.49 percent;
2003 Avg (SE)[B]: 37 (3);
2004 Avg (SE)[B]: 43 (3);
2005 Avg (SE)[B]: 44 (4);
2006[C] Avg (SE)[B]: 44 (3).
Percentage of visits in which patients left before a medical
evaluation[A]: 2.5 percent to 4.49 percent;
2003 Avg (SE)[B]: 49 (4);
2004 Avg (SE)[B]: 60 (4);
2005 Avg (SE)[B]: 58 (6);
2006[C] Avg (SE)[B]: 60 (5).
Percentage of visits in which patients left before a medical
evaluation[A]: 4.5 percent or more;
2003 Avg (SE)[B]: 66 (5);
2004 Avg (SE)[B]: 63 (4);
2005 Avg (SE)[B]: 80 (7);
2006[C] Avg (SE)[B]: 84 (8).
Source: GAO analysis of NCHS data.
[A] NCHS defines the percentage of visits in which patients left before
a medical evaluation as the percentage of visits in which the patient
left after triage but before receiving any medical care.
[B] Avg is the estimated mean and SE is the standard error of the
estimate. Standard error is a statistic used to calculate the range of
values that express the possible difference between the sample estimate
and the actual population value.
[C] These 2006 data exclude outlier data from a single hospital because
a majority of visits to this hospital's emergency department resulted
in lengths of stay that exceeded 24 hours.
[End of table]
Table 15: Percentage of Visits by Emergency Department Length of Stay,
in 2001 through 2006:
Emergency department length of stay: Less than 60 minutes;
2001: 16.6;
2002: 15.8;
2003: 14.0;
2004: 13.9;
2005: 13.7;
2006: 12.8.
Emergency department length of stay: 1 hour or more, but fewer than 2
hours;
2001: 25.1;
2002: 25.5;
2003: 25.2;
2004: 25.2;
2005: 24.8;
2006: 24.0.
Emergency department length of stay: 2 hours or more, but fewer than 4
hours;
2001: 28.5;
2002: 30.4;
2003: 30.9;
2004: 31.0;
2005: 31.5;
2006: 33.0.
Emergency department length of stay: 4 hours or more, but fewer than 6
hours;
2001: 9.1;
2002: 10.8;
2003: 11.5;
2004: 11.7;
2005: 12.8;
2006: 13.9.
Emergency department length of stay: 6 hours or more, but fewer than 10
hours;
2001: 4.2;
2002: 5.2;
2003: 5.7;
2004: 6.0;
2005: 6.9;
2006: 7.3.
Emergency department length of stay: 10 hours or more, but fewer than
14 hours;
2001: 1.5;
2002: 1.4;
2003: 1.4;
2004: 1.4;
2005: 1.9;
2006: 1.7.
Emergency department length of stay: 14 hours or more, but fewer than
24 hours;
2001: 1.5;
2002: 1.4;
2003: 1.4;
2004: 1.3;
2005: 1.6;
2006: 1.0.
Emergency department length of stay: 24 or more hours;
2001: 0.4;
2002: 0.8;
2003: 0.6;
2004: 0.6;
2005: 0.2;
2006: 0.5.
Emergency department length of stay: Blank;
2001: 13.4;
2002: 8.7;
2003: 9.4;
2004: 9.0;
2005: 6.7;
2006: 5.7.
Source: GAO analysis of NCHS data.
Note: Percentages may not sum to 100 because of rounding.
[End of table]
Figure 7: Average and Median Length of Stay in the Emergency
Department, in Minutes, by Acuity Level, in 2001 through 2006:
[Refer to PDF for image: table]
Acuity level[A] (recommended time frame): Immediate[D] (less than 1
minute);
2001, Avg (SE)[B]: 197 (8);
2001, Med[C]: 132;
2002, Avg (SE)[B]: 200 (9);
2002, Med[C]: 139;
2003, Avg (SE)[B]: 221 (11);
2003, Med[C]: 149;
2004, Avg (SE)[B]: 228 (11);
2004, Med[C]: 155;
2005, Avg (SE)[B]: 211 (14);
2005, Med[C]: 143;
2006, Avg (SE)[B]: 238 (12);
2006, Med[C]: 174.
Acuity level[A] (recommended time frame): Emergent[D] (1 to 14
minutes);
2001, Avg (SE)[B]: 197 (8);
2001, Med[C]: 132;
2002, Avg (SE)[B]: 200 (9);
2002, Med[C]: 139;
2003, Avg (SE)[B]: 221 (11);
2003, Med[C]: 149;
2004, Avg (SE)[B]: 228 (11);
2004, Med[C]: 155;
2005, Avg (SE)[B]: 225 (9);
2005, Med[C]: 163;
2006, Avg (SE)[B]: 224 (10);
2006, Med[C]: 168.
Acuity level[A] (recommended time frame): Urgent (15 to 60 minutes);
2001, Avg (SE)[B]: 185 (5);
2001, Med[C]: 128;
2002, Avg (SE)[B]: 191 (7);
2002, Med[C]: 133;
2003, Avg (SE)[B]: 201 (7);
2003, Med[C]: 142;
2004, Avg (SE)[B]: 198 (6);
2004, Med[C]: 143;
2005, Avg (SE)[B]: 208 (6);
2005, Med[C]: 153;
2006, Avg (SE)[B]: 204 (6)
2006, Med[C]: 160.
Acuity level[A] (recommended time frame): Semiurgent (greater than 1
hour to 2 hours);
2001, Avg (SE)[B]: 163 (4);
2001, Med[C]: 124;
2002, Avg (SE)[B]: 183 (8);
2002, Med[C]: 129;
2003, Avg (SE)[B]: 185 (6);
2003, Med[C]: 134;
2004, Avg (SE)[B]: 184 (6);
2004, Med[C]: 129;
2005, Avg (SE)[B]: 188 (6);
2005, Med[C]: 140;
2006, Avg (SE)[B]: 181 (7);
2006, Med[C]: 136.
Acuity level[A] (recommended time frame): Nonurgent (greater than 2
hours to 24 hours);
2001, Avg (SE)[B]: 147 (6);
2001, Med[C]: 108;
2002, Avg (SE)[B]: 155 (7);
2002, Med[C]: 112;
2003, Avg (SE)[B]: 156 (7);
2003, Med[C]: 114;
2004, Avg (SE)[B]: 158 (7);
2004, Med[C]: 115;
2005, Avg (SE)[B]: 161 (5);
2005, Med[C]: 115;
2006, Avg (SE)[B]: 169 (9);
2006, Med[C]: 123.
Acuity level[A] (recommended time frame): No triage[E,F];
2001, Avg (SE)[B]: 176 (12);
2001, Med[C]: 115;
2002, Avg (SE)[B]: 216 (32);
2002, Med[C]: 134;
2003, Avg (SE)[B]: 190 (12);
2003, Med[C]: 131;
2004, Avg (SE)[B]: 191 (9);
2004, Med[C]: 133;
2005, Avg (SE)[B]: 123 (8);
2005, Med[C]: 92;
2006, Avg (SE)[B]: 159 (17);
2006, Med[C]: 101.
Acuity level[A] (recommended time frame): Unknown[F];
2001, Avg (SE)[B]: 176 (12);
2001, Med[C]: 115;
2002, Avg (SE)[B]: 216 (32);
2002, Med[C]: 134;
2003, Avg (SE)[B]: 190 (12);
2003, Med[C]: 131;
2004, Avg (SE)[B]: 191 (9);
2004, Med[C]: 133;
2005, Avg (SE)[B]: 197 (9);
2005, Med[C]: 129;
2006, Avg (SE)[B]: 220 (28);
2006, Med[C]: 141.
Source: GAO analysis of NCHS data.
[A] NCHS developed time-based acuity levels based on a five-level
severity index recommended by the Emergency Nurses Association. The
acuity levels describe the recommended amount of time a patient should
wait to be seen by a physician.
[B] Avg is the estimated mean and SE is the standard error of the
estimate. Standard error is a statistic used to calculate the range of
values that express the possible difference between the sample estimate
and the actual population value.
[C] Med indicates the median measurement.
[D] NCHS added an immediate wait time category to the NHAMCS survey
instrument starting in 2005. For 2001 through 2004, the emergent
category was defined as a visit with a recommended wait time of less
than 15 minutes.
[E] A visit in which there is no mention of an acuity rating or triage
level in the medical record, the hospital did not perform triage, or
the patient was dead on arrival.
[F] For 2001 through 2004, the NHAMCS survey instrument grouped no
triage and unknown triage level into a single category.
[End of figure]
Table 16: Average Length of Stay in the Emergency Department, in
Minutes, by Payer Type, Hospital Type, and Geographic Region, in 2001
through 2006:
Average length of stay in the emergency department by payer type[B]:
Private insurance;
2001 (SE)[A]: 169 (5);
2002 (SE)[A]: 182 (6);
2003 (SE)[A]: 183 (5);
2004 (SE)[A]: 179 (3);
2005 (SE)[A]: 186 (4);
2006 (SE)[A]: 190 (6).
Average length of stay in the emergency department by payer type[B]:
Medicare;
2001 (SE)[A]: 225 (6);
2002 (SE)[A]: 246 (11);
2003 (SE)[A]: 244 (10);
2004 (SE)[A]: 242 (9);
2005 (SE)[A]: 240 (7);
2006 (SE)[A]: 242 (7).
Average length of stay in the emergency department by payer type[B]:
Medicaid/State Children's Health Insurance Program;
2001 (SE)[A]: 171 (5);
2002 (SE)[A]: 172 (6);
2003 (SE)[A]: 176 (6);
2004 (SE)[A]: 183 (6);
2005 (SE)[A]: 188 (7);
2006 (SE)[A]: 188 (5).
Average length of stay in the emergency department by payer type[B]:
Worker's compensation;
2001 (SE)[A]: 116 (5);
2002 (SE)[A]: 130 (10);
2003 (SE)[A]: 132 (8);
2004 (SE)[A]: 128 (6);
2005 (SE)[A]: 115 (7);
2006 (SE)[A]: 131 (6).
Average length of stay in the emergency department by payer type[B]:
Self-pay;
2001 (SE)[A]: 172 (6);
2002 (SE)[A]: 184 (8);
2003 (SE)[A]: 187 (7);
2004 (SE)[A]: 192 (6);
2005 (SE)[A]: 192 (6);
2006 (SE)[A]: 197 (7).
Average length of stay in the emergency department by payer type[B]: No
charge/charity;
2001 (SE)[A]: 223 (12);
2002 (SE)[A]: 274 (19);
2003 (SE)[A]: 267 (20);
2004 (SE)[A]: 279 (29);
2005 (SE)[A]: 257 (16);
2006 (SE)[A]: 247 (19).
Average length of stay in the emergency department by payer type[B]:
Other;
2001 (SE)[A]: 191 (12);
2002 (SE)[A]: 230 (33);
2003 (SE)[A]: 198 (11);
2004 (SE)[A]: 196 (19);
2005 (SE)[A]: 194 (11);
2006 (SE)[A]: 207 (17).
Average length of stay in the emergency department by payer type[B]:
Unknown;
2001 (SE)[A]: 179 (11);
2002 (SE)[A]: 187 (12);
2003 (SE)[A]: 201 (11);
2004 (SE)[A]: 195 (11);
2005 (SE)[A]: 205 (9);
2006 (SE)[A]: 212 (12).
Average length of stay in the emergency department by hospital type:
Voluntary, nonprofit;
2001 (SE)[A]: 177 (5);
2002 (SE)[A]: 193 (7);
2003 (SE)[A]: 193 (5);
2004 (SE)[A]: 189 (4);
2005 (SE)[A]: 198 (4);
2006 (SE)[A]: 195 (5).
Average length of stay in the emergency department by hospital type:
Government[C];
2001 (SE)[A]: 183 (10);
2002 (SE)[A]: 194 (13);
2003 (SE)[A]: 189 (14);
2004 (SE)[A]: 216 (16);
2005 (SE)[A]: 189 (12);
2006 (SE)[A]: 205 (13).
Average length of stay in the emergency department by hospital type:
Proprietary;
2001 (SE)[A]: 175 (13);
2002 (SE)[A]: 172 (16);
2003 (SE)[A]: 195 (17);
2004 (SE)[A]: 176 (16);
2005 (SE)[A]: 191 (12);
2006 (SE)[A]: 218 (33).
Average length of stay in the emergency department by geographic
region[D]: Northeast;
2001 (SE)[A]: 209 (8);
2002 (SE)[A]: 203 (7);
2003 (SE)[A]: 213 (8);
2004 (SE)[A]: 200 (5);
2005 (SE)[A]: 208 (5);
2006 (SE)[A]: 203 (5).
Average length of stay in the emergency department by geographic
region[D]: Midwest;
2001 (SE)[A]: 157 (9);
2002 (SE)[A]: 180 (11);
2003 (SE)[A]: 174 (6);
2004 (SE)[A]: 190 (8);
2005 (SE)[A]: 184 (7);
2006 (SE)[A]: 185 (11).
Average length of stay in the emergency department by geographic
region[D]: South;
2001 (SE)[A]: 173 (6);
2002 (SE)[A]: 184 (7);
2003 (SE)[A]: 191 (9);
2004 (SE)[A]: 186 (6);
2005 (SE)[A]: 189 (7);
2006 (SE)[A]: 206 (10).
Average length of stay in the emergency department by geographic
region[D]: West;
2001 (SE)[A]: 187 (11);
2002 (SE)[A]: 209 (20);
2003 (SE)[A]: 201 (13);
2004 (SE)[A]: 201 (10);
2005 (SE)[A]: 213 (12);
2006 (SE)[A]: 196 (8).
Source: GAO analysis of NCHS data.
[A] Average is the estimated mean and SE is the standard error of the
estimate. Standard error is a statistic used to calculate the range of
values that express the possible difference between the sample estimate
and the actual population value.
[B] In 2001 through 2004, the survey asked for primary expected source
of payment. In 2005 and 2006, multiple sources could be reported. For
the purposes of comparability, in this table, 2005 and 2006 data were
recoded to produce a primary expected source of payment based on this
hierarchy of responses: Medicare, Medicaid, private insurance, worker's
compensation, self-pay, no charge, other, and unknown.
[C] NCHS defines a government-owned hospital as a hospital operated by
a state, county, city, city-county, or hospital district or authority.
[D] NCHS categorizes geographic regions in the NHAMCS as Northeast,
Midwest, South, and West as defined by the U.S. Census Bureau.
[End of table]
Table 17: Average Length of Stay in the Emergency Department, in
Minutes, by Hospitals' Percentage of Visits in Which Patients Left
Before a Medical Evaluation, in 2001 through 2006:
Percentage of visits in which patients left before a medical
evaluation[A]: Less than 1 percent;
2001 (SE)[B]: 137 (7);
2002 (SE)[B]: 150 (12);
2003 (SE)[B]: 147 (6);
2004 (SE)[B]: 152 (6);
2005 (SE)[B]: 145 (6);
2006[C] (SE)b: 150 (8).
Percentage of visits in which patients left before a medical
evaluation[A]: 1 percent to 2.49 percent;
2001 (SE)[B]: 157 (6);
2002 (SE)[B]: 158 (8);
2003 (SE)[B]: 168 (9);
2004 (SE)[B]: 154 (7);
2005 (SE)[B]: 163 (7);
2006[C] (SE)b: 163 (7).
Percentage of visits in which patients left before a medical
evaluation[A]: 2.5 percent to 4.49 percent;
2001 (SE)[B]: 194 (15);
2002 (SE)[B]: 192 (15);
2003 (SE)[B]: 180 (13);
2004 (SE)[B]: 197 (11);
2005 (SE)[B]: 187 (13);
2006[C] (SE)b: 193 (11).
Percentage of visits in which patients left before a medical
evaluation[A]: 4.5 percent or more;
2001 (SE)[B]: 227 (16);
2002 (SE)[B]: 209 (12);
2003 (SE)[B]: 233 (16);
2004 (SE)[B]: 216 (12);
2005 (SE)[B]: 228 (10);
2006[C] (SE)b: 249 (16).
Source: GAO analysis of NCHS data.
[A] NCHS defines the percentage of visits in which patients left before
a medical evaluation as the percentage of visits in which the patient
left after triage but before receiving any medical care.
[B] Average is the estimated mean and SE is the standard error of the
estimate. Standard error is a statistic used to calculate the range of
values that express the possible difference between the sample estimate
and the actual population value.
[C] These 2006 data exclude outlier data from a single hospital because
a majority of visits to this hospital's emergency department had
lengths of stay that exceeded 24 hours.
[End of table]
[End of section]
Appendix V: Comments from the Department of Health and Human Services:
Note: Page numbers in the draft report may differ from those in this
report.
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
April 8, 2009:
Marcia Crosse:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Ms. Crosse:
Enclosed are comments on the U.S. Government Accountability Office's
(GAO) report entitled: Hospital Emergency Departments: Crowding
Continues to Occur and Some Patients Wait Longer Than Recommended Time
Frames (GAO-09-347) and Special Publication-Hospital Emergency
Department: Bibliography (GAO-09-348SP).
The Department appreciates the opportunity to review this report before
its publication.
Sincerely,
Signed by:
Barbara Pisaro Clark:
Acting Assistant Secretary for Legislation:
Attachment:
General Comments Of The Department Of Health And Human Services (HHS)
On The Government Accountability Office's (GAO) Draft Report Entitled:
Hospital Emergency Departments: Crowding Continues To Occur And Some
Patients Wait Longer Than Recommended Time Frames (GAO-09-347):
The Department appreciates the opportunity to review and comment on the
GAO Draft Report and Special Publication entitled, "Hospital Emergency
Departments: Crowding Continues to Occur and Some Patients Wait Longer
Than Recommended Time Frames" (GAO-09-347) and "Hospital Emergency
Department: Bibliography" (GAO-09-348SP), respectively.
The GAO report, an update of a 2003 GAO survey of the extent of
emergency department (ED) crowding, demonstrates that ED waiting times
are continuing to increase and frequently exceed national standards;
particularly at the highest acuity levels, where delays make the
biggest difference. Strengths of the report include its clarity, focus,
and a dispassionate tone.
However, designed as an update, it excluded articles and studies
published before 2003. This method presupposes that readers will be
familiar with the GAO's earlier survey and the large body of literature
presented in it. The valid interpretation of this updated information
would be strengthened by the content and context of the findings and
literature that was reviewed prior to 2003. Moreover, the exclusion of
studies conducted outside the US (such as relevant studies conducted in
Australia, the UK, and Canada) may limit the readers' insight to this
important topic.
Further, the GAO study focuses on the ED and three commonly cited
measures of Crowding. It is worth noting that these are process metrics
and are limited to patient flow within the Emergency Department. This
is potentially important in that they do not provide a direct measure
of broader systematic issues of hospital throughput that effect
emergency department patient flow such as smoothing elective surgery
schedules and facilitating inpatient discharges and bed turnover.
Additionally, information regarding process may not be directly related
to actual patient outcomes such as treatment success or failure,
adverse outcomes or direct harms resulting from the lack of system
capacity. The report does discuss this issue on page 19 under "Impact
of Crowding" and notes the lack of sufficient quantitative evidence to
confirm this assumption, however it may worth specifically noting the
limitations of these three process metrics.
[End of section]
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
Marcia Crosse, (202) 512-7114 or crossem@gao.gov:
Acknowledgments:
In addition to the contact named above, Kim Yamane, Assistant Director;
Danielle Bernstein; Susannah Bloch; Ted Burik; Aaron Holling; Carla
Jackson; Ba Lin; Jeff Mayhew; Jessica Smith; and Jennifer Whitworth
made key contributions to this report.
[End of section]
Footnotes:
[1] S. R. Pitts, R. W. Niska, J. Xu, and C. W. Burt, "National Hospital
Ambulatory Medical Care Survey: 2006 Emergency Department Summary,"
National Health Statistics Reports, no. 7 (2008).
[2] Medicare is the federal health program that covers seniors aged 65
and older and eligible disabled persons. Medicaid is the joint federal
and state program that finances health care for certain low-income
individuals. The State Children's Health Insurance Program finances
health care for low-income, uninsured children whose family incomes
exceed the eligibility limits under their state's Medicaid program.
[3] GAO, Hospital Emergency Departments: Crowded Conditions Vary among
Hospitals and Communities, [hyperlink,
http://www.gao.gov/products/GAO-03-460] (Washington, D.C.: Mar. 14,
2003).
[4] We reported, for example, that two out of three metropolitan
hospitals reported going on ambulance diversion--that is, asking
ambulances to bypass their emergency departments and instead transport
patients to other facilities.
[5] The objectives of this committee, the Committee on the Future of
Emergency Care in the United States Health System, were to (1) examine
the emergency care system in the United States; (2) explore its
strengths, limitations, and future challenges; (3) describe a desired
vision for the system; and (4) recommend strategies for achieving this
vision. The results of the committee's efforts were described in three
IOM reports released in 2006: Hospital-Based Emergency Care: At the
Breaking Point; Emergency Care for Children: Growing Pains; and
Emergency Medical Services: At the Crossroads.
[6] In this report, we use the broader indicator wait times to include
patients leaving before a medical evaluation and intervals of wait
times, such as the amount of time patients wait to see a physician and
the total time patients spend in the emergency department. The National
Center for Health Statistics (NCHS) defines the percentage of visits in
which patients left before a medical evaluation as the percentage of
visits in which the patient left after triage but before receiving any
medical care.
[7] NCHS is an agency within HHS's Centers for Disease Control and
Prevention that compiles statistical information to guide actions and
policies to improve health. NCHS annually collects data on hospital
emergency department utilization in the United States using a
nationally representative survey, the National Hospital Ambulatory
Medical Care Survey (NHAMCS). NCHS uses the NHAMCS to gather, analyze,
and disseminate information on visits to emergency and outpatient
departments of nonfederal, short-stay, and general hospitals in the
United States. NCHS weights sample data from the NHAMCS to produce
national estimates.
[8] AHRQ is an HHS agency that conducts and supports health services
research. AHRQ sponsors the Healthcare Cost and Utilization Project,
which is a family of health care databases and related software tools
and products developed through a federal-state-industry partnership.
Data we reviewed from AHRQ came from the Nationwide Inpatient Sample,
which is one of a number of databases and software tools AHRQ developed
as part of the Healthcare Cost and Utilization Project.
[9] NCHS uses patient acuity levels to measure a patient's severity of
illness. NCHS developed time-based acuity levels based on a five-level
emergency severity index recommended by the Emergency Nurses
Association. The NHAMCS collects data on five levels of acuity:
immediate, emergent, urgent, semiurgent, and nonurgent. Acuity levels
are assigned by medical staff after patients arrive in a hospital's
emergency department.
[10] In addition, for those cases in which we present averages based on
NCHS data, we are presenting the estimated mean as well as the standard
error of the estimate. Standard error is a statistic used to calculate
the range of values that expresses the possible difference between the
sample estimate and the actual population value.
[11] For the literature review, we included articles reporting results
of quantitative analysis, commentaries, articles reporting on
literature reviews, or other articles, which includes articles
published on or between January 1, 2003, and August 31, 2008, that were
identified as a result of our interviews with officials and individual
subject-matter experts, and from searches of related Web sites. Other
articles include articles that were published by professional
associations with reports of their surveys.
[12] NCHS estimates the number of hospitals with an emergency
department that is staffed and operated 24 hours a day.
[13] For the purpose of this report, we use the term metropolitan area
to indicate facilities and visits identified by NCHS as occurring in a
metropolitan statistical area as defined by the Office of Management
and Budget, and nonmetropolitan area to indicate facilities and visits
identified by NCHS as not in a metropolitan statistical area. The
Office of Management and Budget defines a metropolitan statistical area
as an area containing a core-based statistical area associated with at
least one urbanized area that has a population of at least 50,000, plus
adjacent counties having a high degree of social and economic
integration with the core as measured through commuting ties with
counties contained in the core.
[14] Expected sources of payment on the NHAMCS include private
insurance, Medicaid or State Children's Health Insurance Program,
Medicare, self-pay, no charge or charity, worker's compensation, other
sources, and unknown sources.
[15] NCHS defines uninsured patients as those with expected sources of
payment categories of only self-pay, no charge, or charity.
[16] Federal law requires hospitals that participate in Medicare to
screen all people and treat any with emergency medical conditions
regardless of ability to pay. In certain circumstances, hospitals can
place themselves on diversionary status and direct certain en route
ambulances to other hospitals when they are unable to accept additional
patients.
[17] While researchers have been using diversion, wait times (including
patients leaving before a medical evaluation), and boarding as
indicators that point to situations in which crowding is likely
occurring, there is still no standard measure to quantify the extent to
which emergency departments are experiencing crowded conditions. In the
absence of a widely-accepted standard measure of crowding, researchers
have proposed and conducted limited testing of potential measures of
crowding. None of these measures of crowding, however, have been widely
implemented by researchers and health care practitioners. See appendix
III for additional information on these potential measures.
[18] NCHS defines the percentage of visits in which patients left
before a medical evaluation as the percentage of visits in which the
patient left after triage but before receiving any medical care.
[19] See, B. R. Asplin et al., "A Conceptual Model of Emergency
Department Crowding," Annals of Emergency Medicine, vol. 42, no. 2
(2003): 173-180.
[20] The average hours spent on diversion in 2003 was 276 hours with a
standard error of 42. The average hours spent on diversion in 2006 was
473 hours with a standard error of 73. Standard error is a statistic
used to calculate the range of values that expresses the possible
difference between the sample estimate and the actual population value.
[21] Diversion data were missing for 3.75 percent of emergency
departments in 2003, for 24.1 percent in 2004, for 29.1 percent in
2005, and for 20.5 percent in 2006.
[22] For 2005 and 2006 the sample sizes were insufficient to calculate
the average number of hours that nonmetropolitan hospitals reported
going on diversion. Therefore, we were not able to compare the number
of hours metropolitan and nonmetropolitan hospitals reported spending
on diversion.
[23] C. W. Burt and L. F. McCaig, "Staffing, Capacity, and Ambulance
Diversion in Emergency Departments: United States, 2003-04," Advance
Data From Vital and Health Statistics, no. 376 (2006).
[24] For 2003 and 2004, 8 percent of all hospitals reported that their
state or local laws prohibit diversion. According to NCHS, some
hospitals that reported state laws prohibiting diversion also reported
diversion hours. NCHS reported that the reasons for this are unknown
but could include respondent or key error, allowable diversions within
state laws that prohibit only certain types of diversion, change in
state law after the diversion reporting period, or other factors. We
did not attempt to validate the number of state or local laws that may
govern ambulance diversion.
[25] American Hospital Association, "The State of America's Hospitals,"
Taking the Pulse, A Chartpack (Washington, D.C., April 2006),
[hyprlink, http://www.aha.org/aha/research-and-trends/health-and-
hospital-trends/2006.html] (accessed June 26, 2008); and American
Hospital Association, "The 2007 State of America's Hospitals," Taking
the Pulse, (Washington, D.C., July 2007), [hyperlink,
http://www.aha.org/aha/research-and-trends/health-and-hospital-
trends/2007.html] (accessed June 26, 2008).
[26] In its 2006 survey, the American Hospital Association surveyed
about 4,900 community hospital chief executive officers and received
1,011 responses, a response rate of 20 percent. Of those hospitals that
responded, about 425 hospitals (about 42 percent of respondents)
reported going on diversion at least once during the year. In its 2007
survey, the American Hospital Association surveyed about 5,000
community hospital chief executive officers and received 840 responses,
a response rate of 17 percent. Of those hospitals that responded to the
survey, about 302 hospitals (about 36 percent of respondents) reported
going on diversion at least once during the year.
[27] The Abaris Group, California Emergency Department Diversion
Project, Report One (Oakland, Calif.: California HealthCare Foundation,
March 2007). [hyperlink,
http://www.caeddiversionproject.com/uploads/CAEDDiversionProjectReportOn
e3-21-07.pdf] (accessed Sept. 4, 2008).
[28] Maryland Health Care Commission, Use of Maryland Hospital
Emergency Departments: An Update and Recommended Strategies to Address
Crowding (Baltimore, Md., January 2007), [hyperlink,
http://mhcc.maryland.gov/hospital_services/acute/emergencyroom/](accesse
d Sept. 17, 2008).
[29] In California, the total number of hours that hospitals statewide
reported being on diversion decreased overall, from almost 300,000
hours in 2003 to less than 200,000 hours in 2006. The number of hours
spent on diversion in individual counties, however, varied over these 3
years, with some counties reporting increases and others reporting
decreases. In Maryland, the percentage of time hospitals statewide
reported being on diversion increased from 2003 to 2006. Hospitals
reported that 9.8 percent and 11.5 percent of their total available
hours were spent on diversion in 2003 and 2006, respectively.
[30] NCHS did not collect the average wait time to see a physician in
2001 and 2002.
[31] According to NCHS, from 2003 to 2006 the increases in average wait
times to see a physician for visits overall and by emergent, urgent,
and semiurgent patients were statistically significant.
[32] NCHS defines emergent patients as patients who, based on triage,
are recommended to be seen by a physician within 1 to 14 minutes.
[33] For 2003 and 2006 estimates of average wait time to see physicians
at metropolitan hospitals the standard errors are within 2 minutes. For
2003 and 2006 estimates of average wait time to see a physician at
nonmetropolitan hospitals the standard errors are within 4 minutes.
[34] Institute of Medicine, Future of Emergency Care, Hospital-Based
Emergency Care: At the Breaking Point (Washington, D.C.: The National
Academies Press, 2006).
[35] L. Fryman and L. Murray, "Managing Acute Head Trauma in a Crowded
Emergency Department," Journal of Emergency Nursing, vol. 33, no. 3
(2007).
[36] Institute of Medicine, Hospital-Based Emergency Care, 154.
[37] American College of Emergency Physicians, On-call Specialist
Coverage in U.S. Emergency Departments (Irving, Tex., 2006).
[38] Institute of Medicine, Hospital-Based Emergency Care, 4.
[39] C. E. Begley et al., "Emergency Department Diversion and Trauma
Mortality: Evidence from Houston, Texas," The Journal of Trauma,
Injury, Infection, and Critical Care, vol. 57, no. 6 (2004).
[40] J. M. Pines et al., "The Association between Emergency Department
Crowding and Hospital Performance on Antibiotic Timing for Pneumonia
and Percutaneous Intervention for Myocardial Infarction," Academic
Emergency Medicine, vol. 13 no. 8 (2006). The Joint Commission
(formerly the Joint Commission on Accreditation of Healthcare
Organizations) and the Centers for Medicare & Medicaid Services have
published measures of emergency department quality, including the
percentage of patients with community-acquired pneumonia that receive
antibiotics within 4 hours of presenting at an emergency department.
[41] D. B. Chalfin et al., "Impact of Delayed Transfer of Critically
Ill Patients from the Emergency Department to the Intensive Care Unit,"
Critical Care Medicine, vol. 35, no. 6 (2007).
[42] The National Health Policy Forum is a nonpartisan organization
that provides information on health policy issues and works to foster
more informed government decision making. It serves primarily senior
staff in Congress, the executive branch, and congressional support
agencies.
[43] J. Taylor, Don't Bring Me Your Tired, Your Poor: The Crowded State
of America's Emergency Departments (Washington, D.C.: National Health
Policy Forum, 2006).
[44] See for example, American College of Emergency Physicians,
Emergency Department Crowding: High-Impact Solutions (Irving, Tex.,
2008).
[45] No factor other than a lack of inpatient beds was reported in the
articles we reviewed as the main factor contributing to crowding. The
next factor most commonly reported as one of a number of factors
contributing to crowding was a lack of access to primary care, reported
in 22 articles.
[46] Institute of Medicine, Hospital-Based Emergency Care, 137.
[47] Data we reviewed from AHRQ came from the Nationwide Inpatient
Sample, which is one of a number of databases and software tools AHRQ
developed as part of the Healthcare Cost and Utilization Project.
[48] The Centers for Medicare & Medicaid Services uses DRGs to
establish payment rates for hospitals that provide medical and surgical
services to patients with Medicare.
[49] In addition, available data from AHRQ's Healthcare Cost and
Utilization Project indicate that the source of payment for admissions
from the emergency department differs in some cases from the source of
payment for admissions for elective surgeries. For example, for 2006,
AHRQ estimates that of hospital admissions from the emergency
department, the source of payment was private insurance for 25 percent
of admissions, Medicare for 49 percent of admissions, Medicaid for 15
percent of admissions, uninsured for 8 percent of admissions, and other
sources for 4 percent of admissions. In the same year, AHRQ estimates
that of hospital admissions for elective surgeries, the source of
payment was private insurance for 46 percent of admissions, Medicare
for 32 percent of admissions, Medicaid for 15 percent of admissions,
uninsured for 3 percent of admissions, and other sources for 4 percent
of admissions.
[50] D. C. Brousseau et al., "The Effect of Prior Interactions with a
Primary Care Provider on Nonurgent Pediatric Emergency Department Use,"
Archives of Pediatric & Adolescent Medicine, vol. 158, no. 1 (2004).
[51] D. DeLia, Potentially Avoidable Use of Hospital Emergency
Departments in New Jersey (New Brunswick, N.J.: Rutgers Center for
State Health Policy, 2006).
[52] S. Lambe et al., "Waiting Times in California's Emergency
Departments," Annals of Emergency Medicine, vol. 41, no. 1 (2003).
[53] P. Cunningham and J. May, "Insured Americans Drive Surge in
Emergency Department Visits," Issue Brief, no. 70 (Washington, D.C.:
Center for Studying Health System Change, October 2003).
[54] Institute of Medicine, Hospital-Based Emergency Care, 218.
[55] American Hospital Association, "The 2007 State of America's
Hospitals," Taking the Pulse (Washington, D.C., July 2007), [hyperlink,
http://www.aha.org/aha/research-and-trends/health-and-hospital-
trends/2007.html] (accessed June 26, 2008).
[56] American College of Emergency Physicians, ACEP Psychiatric and
Substance Abuse Survey 2008 (Dallas, Tex., 2008).
[57] The standard error is within 80 minutes for average length of stay
in the emergency department for patients presenting with a complaint of
a psychological or mental disorder in 2006. The standard error is
within 4 minutes for average length of stay in the emergency department
for all other patients in 2006.
[58] Institute of Medicine, Hospital-Based Emergency Care, 39, 56, 129,
137.
[59] NCHS annually collects national health statistical information on
hospital emergency department utilization in the United States using a
nationally representative survey, the NHAMCS. NCHS uses the NHAMCS to
gather, analyze, and disseminate information on visits to emergency and
outpatient departments of nonfederal, short-stay, and general hospitals
in the United States. A complex, multistage sample design is used in
the NHAMCS, which includes primary sampling units (geographic areas
such as counties or groups of counties), hospitals within these units,
clinics within outpatient departments, and patient visits within
emergency departments and clinics. Sample data are weighted to produce
national estimates. The scope of the emergency department component of
the NHAMCS includes emergency departments that are staffed and operated
24 hours a day.
[60] The data provided by NCHS were estimates. Each estimate has a
standard error associated with it. For the purposes of this report, we
report standard errors for averages.
[61] NCHS began collecting data on diversion in a supplement to the
NHAMCS that covered the 2-year period of 2003 through 2004. Beginning
in 2005, NCHS included a question about diversion on the NHAMCS. Due to
the low response rates for the NHAMCS questions about diversion in
2004, 2005, and 2006, we were unable to analyze diversion by
characteristics such as hospital type or geographic region. For 2005
and 2006 the sample sizes were insufficient to calculate the number of
hours that nonmetropolitan hospitals reported being on diversion.
Therefore, we were not able to compare the number of hours metropolitan
and nonmetropolitan hospitals reported spending on diversion for those
years.
[62] NCHS did not collect data on wait times to see a physician in 2001
or 2002.
[63] To measure severity of illness, NCHS developed time-based acuity
levels based on a five-level severity index recommended by the
Emergency Nurses Association. The acuity levels describe the
recommended amount of time a patient should wait to be seen by a
physician. In the 2006 NHAMCS, NCHS collected data on five levels of
acuity: immediate, emergent, urgent, semiurgent, and nonurgent.
[64] NCHS uses voluntary nonprofit, government, and proprietary to
distinguish hospital ownership. NCHS defines a government-owned
hospital as a hospital operated by a state, county, city, city-county,
or hospital district or authority.
[65] For the purpose of this report, we use the term metropolitan area
to indicate facilities and visits identified by NCHS as occurring in a
metropolitan statistical area as defined by the Office of Management
and Budget, and nonmetropolitan area to indicate facilities and visits
identified by NCHS as not in a metropolitan statistical area. The
Office of Management and Budget defines a metropolitan statistical area
as an area containing a core-based statistical area associated with at
least one urbanized area that has a population of at least 50,000, plus
adjacent counties having a high degree of social and economic
integration with the core as measured through commuting ties with
counties contained in the core.
[66] NCHS categorizes geographic regions in the NHAMCS as Northeast,
Midwest, South, and West as defined by the U.S. Census Bureau.
[67] Medicare is the federal health program that covers seniors aged 65
and older and eligible disabled persons. Medicaid is the joint federal
and state program that finances health care for certain low-income
individuals. The State Children's Health Insurance Program finances
health care for low-income, uninsured children whose family incomes
exceed the eligibility limits under their state's Medicaid program.
[68] AHRQ sponsors the Healthcare Cost and Utilization Project, which
is a family of health care databases and related software tools and
products developed through a federal-state-industry partnership. The
Healthcare Cost and Utilization Project databases bring together the
data-collection efforts of state data organizations, hospital
associations, private data organizations, and the federal government to
create a national information resource of patient-level health care
data. Data we reviewed from AHRQ came from the Nationwide Inpatient
Sample, which is one of a number of databases and software tools AHRQ
developed as part of the Healthcare Cost and Utilization Project.
[69] The Centers for Medicare & Medicaid Services uses DRGs to
establish payment rates for hospitals that provide medical and surgical
services to Medicare beneficiaries.
[70] We also analyzed data from AHRQ's Healthcare Cost and Utilization
Project on the source of payment for hospital admissions from the
emergency department and admissions not from the emergency department
in 2006.
[71] In addition, for those cases in which we present averages based on
NCHS data, we are presenting the estimated mean and as well as the
standard error of the estimate. Standard error is a statistic used to
calculate the range of values that expresses the possible difference
between the sample estimate and the actual population value.
[72] For example, we compared data on the estimated number of emergency
departments operating in the United States in 2006 from NCHS with the
number of emergency departments operating in the United States in 2006
from the American Hospital Association and found differences. We
discussed the discrepancy with NCHS officials and, because we chose in
this report to use other NCHS estimates, we used NCHS's estimates of
the number of emergency departments throughout the report.
[73] For the literature review, we included articles reporting results
of quantitative analysis, commentaries, articles reporting on
literature reviews, or other articles, including those identified as a
result of our interviews with officials and individual subject-matter
experts, and from searches of related Web sites. In total, we reviewed
80 articles reporting on quantitative analysis, 64 commentaries, 8
articles reporting on literature reviews, and 45 other articles.
[74] Officials at the Center for Studying Health System Change are
researchers who interviewed providers from across the country.
[75] We obtained NCHS data beginning with 2001 because these data
became publicly available in 2003 or later, meeting the criterion for
inclusion in our analysis. At the time we conducted our analysis, the
most recent year for which data were available from NCHS on emergency
department utilization was 2006.
[76] The National Center for Health Statistics (NCHS) defines the
percentage of patients who left before a medical evaluation as the
percentage of visits in which the patient left after triage but before
receiving any medical care.
[End of section]
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