North Carolina

Category Grades
32C- 13C
Access to Emergency Care:
34D- 27D
Quality/Patient Safety:
5A 4A-
Medical Liability:
46F 24C
Public Health/ Injury Prevention:
23C 23C-
Disaster Preparedness:
20B- 27C-

North Carolina has made excellent progress in improving its Medical Liability Environment since 2009, which is reflected in its overall performance. However, critical issues hindering Access to Emergency Care have not been adequately addressed and continue to burden the entire emergency care system.

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North Carolina should be applauded for passing legislation to improve the Medical Liability Environment, including a requirement that clear and convincing evidence be provided as proof of medical negligence in suits related to the provision of care mandated by the Emergency Medical Treatment and Labor Act (EMTALA), adding one additional layer of liability protection for physicians who provide emergency care. The state also instituted a $500,000 medical liability cap on non-economic damages in 2011. Since 2009, North Carolina has seen average medical liability insurance premiums decrease by more than 25% for both primary care physicians and specialists. Average medical malpractice award payments decreased as well.

North Carolina received high marks in Quality and Patient Safety for having implemented a prescription drug monitoring program that monitors drug schedules II to V; putting in place stroke and ST-elevation myocardial infarction (STEMI) systems of care, including destination policies that allow emergency medical services to bypass local hospitals to take patients to hospital specialty centers; and ranking third in the nation for fewest minutes before outpatients with chest pain were transferred to an appropriate hospital (47 minutes). Nearly 97% of the state's hospitals have electronic medical records, and 58.3% have or are planning to develop a diversity strategy or plan. In addition, 97% of patients with acute myocardial infarction were given percutaneous coronary intervention within 90 minutes of arrival, up from 70% in 2009, ranking second in the nation.


North Carolina made limited progress regarding Access to Emergency Care since the 2009 Report Card. While increasing the proportion of the population within 60 minutes of a level I or II trauma center (94.1%) and the number of accredited chest pain centers per capita (3.5 per 1 million people), the state lost ground in the number of staffed inpatient beds and emergency departments (ED) per capita (289.6 per 100,000 and 11.2 per 1 million people, respectively). North Carolina also continues to have a high hospital occupancy rate (70.7 per 100 staffed inpatient beds) and a low rate of psychiatric care beds (21.9 per 100,000 people).

North Carolina's Public Health and Injury Prevention grade reflects a mix of adequate and poor performance. For instance, while the state has relatively high rates of vaccination among the elderly, only 75.3% of children receive the full schedule of immunizations, down from 84.3% in 2009. North Carolina also has higher-than-average obesity rates among adults and children, contributing to an overburdened medical system.

North Carolina's performance in Disaster Preparedness fell slightly since 2009, resulting in an average grade. Only about a third of registered nurses in North Carolina report receiving training in emergency preparedness, compared to about 40% nationally.


While North Carolina has made great progress in improving its Medical Liability Environment, the state must be vigilant in maintaining recent reforms, such as additional liability protections for EMTALA-mandated care and medical liability caps on non-economic damages. Additional reforms should be considered, including abolishing joint and several liability and providing for malpractice award payments to be offset by collateral sources.

North Carolina must act immediately to address its many issues related to Access to Emergency Care. The number of physicians accepting Medicare has dropped to only 2.5 per 100 Medicare beneficiaries, an access problem likely to be exacerbated by an aging population. With regard specifically to emergency care, the state must work with hospitals and mental health providers to increase the availability of psychiatric care beds and access to community mental health services in order to prevent boarding of mental health patients in the ED. The state needs to work to reduce ED wait times, which average 312 minutes from ED arrival to ED departure for admitted patients.

Access to Emergency Care

Title 2009
Report Card
Report Card
Board-certified emergency physicians per 100,000 pop 9.2 10.3
Emergency physicians per 100,000 pop 12 13.5
Neurosurgeons per 100,000 pop 1.8 1.8
Orthopedists and hand surgeon specialists per 100,000 pop 8.8 8.9
Plastic surgeons per 100,000 pop 1.9 1.9
ENT specialists per 100,000 pop 3.5 3.6
Registered nurses per 100,000 pop 903 946
Percent of children able to see provider 95.7
Level I or II trauma centers per 1M pop 1 0.7
Percent of population within 60 minutes of Level I or II trauma center 86 94.1
Accredited chest pain centers per 1M pop 1 3.5
Percent of population with an unmet need for substance abuse treatment 7.5 7.2
Pediatric specialty centers per 1M pop 3 2.4
Medicaid fee levels for office visits as a percent of the national average 127.4 115.6
Percent change in Medicaid fees for office visits (2004-05 to 2007/2007 to 2012) 0 11.5
Percent of adults with no health insurance 19.2 18.6
Percent of adults underinsured 8.8
Percent of children with no health insurance 14 9.3
Percent of children underinsured 18
Percent of adults with Medicaid 8.1 9.5
Hospital closures in 2006/2011 1 0
Staffed inpatient beds per 100,000 pop 321.5 289.6
Hospital occupancy rate per 100 staffed beds 71.9 70.7
Psychiatric care beds per 100,000 pop 19.5 21.9
Median time from ED arrival to ED departure for admitted ED patients 312
State collects data on diversion YES YES

Disaster Preparedness

Title 2009
Report Card
Report Card
Per capita federal disaster preparedness funds $6.79 $4.20
State budget line item health care surge NO
ESF-8 plan is shared with all EMS and essential hospital personnel YES YES
Emergency physician input into the state planning process YES, YES YES
Public health and emergency physician input during an ESF-8 response YES
Drills, exercises conducted involving hospital personnel, equipment, or facilities per hospital
Accredited by the Emergency Management Accreditation Program (EMAP) NO YES
Special needs patients included in medical response plan YES YES
Patients dependent on medication for chronic conditions in medical response plan NO YES
Medical response plan for supplying dialysis NO YES
Mental health patients included in medical response plan YES
Medical response plan for supplying psychotropic medications YES
Mutual aid agreements in place with behavioral health providers LOCAL LEVEL
State requires long-term care and nursing home facilities to have a written disaster plan YES
State able to report number of exercises involving long-term care facilities or nursing NO
Just-in-time training systems in place STATWIDE STATEWIDE
Statewide medical communication system with one layer of redundancy YES YES
Statewide patient tracking system YES NO
Statewide real-time or near real-time syndromic surveillance system YES YES
Real-time surveillance system in place for common ED presentations YES YES, STATEWIDE
Bed surge capacity per 1M pop NR 1,516
ICU beds per 1M pop 284.7 258.5
Burn unit beds per 1M pop 3 6.2
Verified burn centers per 1M pop 0.110362705 0
Physicians registered in ESAR-VHP per 1M pop 11.8 43.3
Nurses registered in ESAR-VHP per 1M pop 39.2 199.9
Behavioral health professionals registered in ESAR-VHP per 1M pop 5.6
Strike teams or medical assistance teams YES YES
Disaster training required for essential hospital/EMS personnel YES, YES NO, YES
Percent of RNs that received emergency training 39.5 34

Medical Liability Environment

Title 2009
Report Card
Report Card
Lawyers per 10,000 pop 10.8 10.9
Lawyers per physician 0.4 0.4
Lawyers per emergency physician 8.8 8.1
ATRA judicial hellholes (2009 range 0 to -7/2014 range 2 to -6) 0 0
Malpractice award payments per 100,000 pop 0.8 1.5
Average malpractice award payments $286,765 $242,973
National Practitioner Databank reports per 1,000 physicians 11.9 17.2
Apology laws: Apology is inadmissible as evidence in a court of law YES
State has implemented a patient compensation fund NO NO
Number of insurers writing medical liability policies per 1,000 physicians 3.2 3.7
Average medical liability insurance premiums for primary care physicians $14,090 $9,976
Average medical liability insurance premiums for specialists $65,662 $48,712
Presence of pretrial screening panels NONE NO
Pretrial screening panel's findings admissible as evidence N/A N/A
Periodic payments are: required, granted upon request, at court's discretion NO NO
Medical liability cap on non-economic damages NONE $350,001-500,000
Additional liability protection for EMTALA-mandated emergency care NO YES
Joint and several liability abolished NO NO
Collateral Source Rule/Provides for Awards to be Offset NO
State provides for case certification NO NO
Expert witness required to be of the same specialty as the defendant YES YES
Expert witness must be licensed to practice medicine in the state NO NO

Public Health & Injury Prevention

Title 2009
Report Card
Report Card
Bicyclist fatalities per 100,000 cyclists 10
Pedestrian fatalities per 100,000 pedestrians 9
Percent of traffic fatalities alcohol-related 36 34
Percent of front occupants using restraints 88.8 89.5
Child safety seat/seat belt legislation - score out of a possible 10 points 8 8
Helmet use required for all motorcylce riders YES YES
Distracted driving legislation score - out of a possible 4 points 2
Graduated drivers' licenses legislation score -out of a possible 5 points 0
Percentage of children aged 19-35 months who are immunized 84.3 75.3
Percentage of adults aged 65+ who rec’d an influenza vaccine in the last 12 mos 69.6 66.6
Percentage of adults aged 65+ who ever rec’d pneumococcal vaccine 68.5 72.1
Fatal occupational injuries per 1M workers 40.8 31.4
Homicides and suicides (non-motor vehicle)(per 100,000) 19.3 18.7
Unintentional fall-related fatal injuries (per 100,000) 7.1 9
Fire/burn related fatal injuries (per 100,000) 1.5 1.1
Rate of unintentional firearm-related fatal injuries (per 100,000) 0.3 0.3
Rate of unintentional poisoning-related deaths (per 100,000) 10.1
Total injury prevention funds per 1,000 persons $265.89 $288.47
Dedicated child injury prevention funding YES
Dedicate elderly injury prevention funding NO
Dedicated occupational injury prevention funding NO
Anti-smoking legislation score - score out of a possible 3 points 2
Infant mortality rate per 1,000 live births 8.8 7
Percentage of adults who binge drink 11.3 15.2
Percentage of adults who currently smoke 22.1 21.8
Percentage of adult population who are obese (BMI > 30.0) 26.6 29.1
Percentage of children who are obese 16.1
Cardiovascular disease disparity ratio 3.7
HIV diagnosis disparity ratio 11.9
Infant mortality disparity ratio 2.8

Quality & Patient Safety

Title 2009
Report Card
Report Card
Funding for quality improvement within the EMS system YES NO
Funded state EMS medical director YES YES
Emergency medicine residents per 1M pop 16 17.8
Adverse event reporting required NO NO
% of counties with Enhanced 911 capability 100 100
State has a uniform system for providing pre-arrival instructions YES YES
State uses CDC guidelines for state field triage protocols YES (2011)
State has or is working on a stroke system of care YES YES
State has triage and destination policy in place for stroke patients YES
State has or is working on a PCI network or a STEMI system of care YES YES
State has triage and destination policy in place for STEMI patients YES
State maintains statewide trauma registry YES YES
State has triage and destination policy in place for trauma patients YES
Prescription drug monitoring program score (range 0-4) 3
% of hospitals with computerized practitioner order entry 21.6 73.2
% of hospitals with electronic medical records 56.9 96.7
% of patients with AMI given PCI within 90 minutes of arrival 70 97
Median time to transfer to another facility for acute coronary intervention 47
% of patients with AMI who received aspirin within 24 hours 99
% of hospitals collecting data on race/ethnicity and primary language 71.5
% of hospitals with or planning to develop a diversity strategy or plan 58.3

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