Overview

Perceptions and Reality

It is the inescapable conclusion of numerous research studies: hospitals are crowded, emergency departments are backed up, ambulance diversions are common and patients are facing longer waits.

Despite this reality, for much of the American public, the crisis in emergency care is all but invisible. Opinion polls suggest that the public understands that there is a health care crisis in general, and that emergency departments are crowded with long waits for care. However, most people believe that the conditions of emergency departments across the country resemble those they see on television shows.¹ While they may recognize that crowding is a problem and wait times can be long, they do not believe these issues will affect them personally. Many also believe, mistakenly, that their local hospital is a trauma center, although this is only the case in eight percent or less of all U.S. hospitals.²

The gap between public perception and the reality of emergency medicine underscores the critical need to more clearly paint the true, full picture of emergency care in our country.

Facts About Emergency Department Visits Number of visits: 119.2 million or 227 visits per minute Number of injury-related visits: 35.6 million Number of visits per 100 persons: 40.5 Percent increase in emergency department visits from 1996 – 2006: 32 percent Percent of ambulatory medical care visits that occur in emergency departments: 11 percent Percent of active physicians that are emergency physicians: 3.3 percent Source: National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary

This Report Card is designed to help bridge this gap by assessing the multiple factors that affect the provision of emergency medical care. The 2009 Report Card includes a wide range of indicators that measure not only issues such as capacity and utilization but also the degree to which state and national policies support emergency care and the broader health systems with which it is so closely interconnected.

While the Report Card presents as full a picture as possible of the status of the emergency medicine environment in our nation, it is not designed to assess specific emergency departments or hospitals, nor does it measure the quality of emergency care provided in any particular facility in any given state.  However, recognizing that a lack of adequate support for emergency services can negatively impact care, the Report Card is intended to assess the level of that support and the overall environment in which emergency care providers operate.

National Emergency Health Care Environment

Emergency medicine plays a crucial role in our nation’s health care system. Not only do emergency departments provide emergency care in critical situations, but they also serve as a health care safety net for anyone who cannot access the care they need elsewhere. Every year, tens of millions of people across the United States seek emergency care and the demand for that care continues to rise while resources decline. According to government statistics, there were 119.2 million emergency department visits in 2006, compared with 90.3 million visits in 1996 – representing a 32 percent increase in just one decade.³ Americans believe that when they call 911 or go to their local hospital emergency department, it will be open, properly staffed, and ready to provide the care they need, regardless of their ability to pay. If emergency departments are to continue providing those critical services, substantial changes will have to be made.

Rising Demand

All indications suggest that the use of emergency departments will continue to rise due to factors such as the increasing age of the population and other changing demographics, large numbers of uninsured and underinsured, and decreasing access to primary and specialty health care services. Indeed, the demographic pressures on emergency departments are substantial. Older patients represent the fastest growing population of emergency department users. Visits by individuals aged 65–74 rose by more than 30 percent from 1993 to 2003, and by 2013 they are expected to have doubled since 1993.⁴ The impact of this demographic shift will be significant and long lasting. Patients over the age of 65 are more likely to visit the emergency department than younger people, are more likely to have longer emergency department stays, and are more likely to be admitted to the hospital.⁴

Further factors leading to an increased demand for emergency services include the rising numbers of individuals who cannot afford medical care or have nowhere else to go. While it is commonly thought that this primarily applies to the underinsured and uninsured, the emergency department has also become a health care safety net for individuals who have insurance, but are unable to obtain appointments with primary care physicians or medical specialists in a timely manner. This includes individuals who have health care coverage through Medicaid or Medicare, but cannot find physicians willing to accept their coverage.

The Emergency Medical Treatment and Labor Act (EMTALA) ensures that every emergency department patient, regardless of insurance status or ability to pay, will be examined and stabilized if needed. As a result of this unfunded government mandate, many hospital emergency departments provide an extensive amount of uncompensated care, which has contributed to hospital and emergency department closures and reductions in lifesaving emergency resources for everyone.

Boarding and Crowding

Critical factors affecting patients’ ability to access timely emergency care include a shrinking supply of inpatient hospital beds and nurses available to staff those beds. As a result, many admitted patients end up being “boarded” in the emergency department, where they spend hours or even days waiting for a bed in the appropriate inpatient service setting. Boarded patients are often forced to wait in emergency department hallways, waiting rooms, or other available spaces – none of which provide a suitable environment or ensure that they receive the specialized services they need. At the same time, boarded patients tie up emergency staff time and resources, which in turn limits emergency department capacity for treating other patients. This leads to increased waiting times for new arrivals and raises the risk that the hospital will have to divert incoming ambulances to other sites.

Another critical factor affecting access is the shortage of on-call specialists available to the emergency department. This shortage, caused in part by low reimbursement and high medical liability costs, may lead to unnecessary and potentially dangerous delays for patients. Further delays occur when patients need to be transferred to other facilities in order to receive the specialty care they need. In both instances, emergency department resources that would otherwise be used to help other patients awaiting emergency care are tied up.

Despite the growing demand for their services, the available pool of emergency departments is shrinking. Increasing numbers of hospitals and trauma centers are closing their emergency departments due to factors that include low reimbursement rates from public and private insurers, high proportions of uncompensated care, workforce shortages in emergency medicine, high medical liability risks, and a lack of access to on-call specialists. The emergency departments that remain open are increasingly crowded, over capacity, and overwhelmed.⁵

Comments from Emergency Physicians "We are now boarding psychiatric patients in our emergency department for more than 2 days, because there is no place to transfer them. They receive minimal medical care and no psychiatric care during that time."

In 2007, the American College of Emergency Physicians (ACEP) conducted a poll of emergency physicians to measure critical issues facing emergency patients.⁶ At that time, nearly 80 percent of the 1,500 emergency physicians responding to the poll said they had significant concerns about the crowded conditions in their emergency departments. Half reported personally encountering a patient who had suffered because of “boarding,” and 200 said they knew of patients who had died because of the practice. Further, numerous studies have now linked emergency department crowding and the boarding of patients with compromises in clinical care:

• In the United States, one study demonstrated increased mortality in critically ill patients boarded in the emergency department longer than six hours.⁷
• Another United States study showed that elderly patients who are boarded in the emergency department for longer than six hours are more than four times more likely than those who spend a shorter time in the emergency department to be discharged to a nursing home rather than to their own homes.⁸
• Additional United States studies have linked emergency department crowding with significant delays in the administration of lifesaving antibiotics and pain medications.^9,10
• In Canada, according to one study, heart attack patients treated in a crowded emergency system were 40 percent more likely to experience delays in receiving thrombolytic (clot-busting) medication.¹¹  
• In Australia, emergency department crowding has been linked with an overall increase in patient mortality.¹² 

The findings from the 2007 ACEP poll also suggest that 90 percent of emergency departments are already over capacity. More than 80 percent of respondents indicated that crowding had worsened in their emergency departments over the past year. Nearly 70 percent reported that boarding of admitted patients was frequent or constant. In addition, 50 percent reported that they were forced to divert ambulances to other hospitals because of lack of capacity, with 10 percent reporting that they had to go on ambulance diversion every day or most days, 14 percent reporting diversion of ambulances several times a week, and 12 percent reporting diversions once or twice a week.⁶  Hospitals with high patient volumes and those located in metropolitan areas are more likely than others to be forced to divert ambulances because of crowding and capacity constraints.

Impact on Patients and Disaster Response

The results of increased demand, crowding, and diminished resources for emergency departments are felt acutely by patients who face increasing delays in care, even when they are in pain or experiencing a heart attack. The average waiting time to see a physician in the emergency department has more than doubled in the last decade;¹³ it is currently just under one hour (55.8 minutes).³ Waits are far shorter for more urgent triage categories, though these, too, have increased over time. The average time spent by a patient in the emergency department is 4 hours, with longer waits in emergency departments that experience high patient volumes.¹⁴

Comments from Emergency Physicians "Our emergency departments are feeling the impact of hospital crises, nursing shortages, and physician shortages that are leading to boarding across the entire state and affect every hospital from the smallest rural hospital to the largest tertiary facility."

In a 2006 report, the Institute of Medicine (IOM) described hospital-based emergency care as being “at the breaking point,” with many emergency departments stretched to the limits of their capacity and beyond.^5,15  The increasing demands on emergency departments raise enormous concerns and clearly do not bode well for the provision of timely and quality emergency services.

This situation raises even greater concerns regarding the ability of the emergency medicine system to respond to the extraordinary demands of a catastrophic disaster. In the face of potential terrorist attacks, major disease outbreaks, or natural disasters, hospitals and emergency departments must be able to absorb even greater demands for emergency services and resources. As a result, surge capacity and other disaster preparedness issues have become major concerns for our nation’s emergency care system.