Hospital Emergency Departments: Crowding Continues to Occur, and Some Patients Wait Longer than Recommended Time Frames
Published: 2009-04-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: 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. These programs— Medicare, Medicaid, and the State Children’s Health Insurance Program— 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. 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,  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. 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, 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) and data on hospital admissions—which were related to factors  of crowding—from the Agency for Healthcare Research and Quality  (AHRQ). 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. 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. 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) 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.
subsections: section_title: Background
paragraphs: 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.
subsections: section_title: Emergency Department Utilization
paragraphs: 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. 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.)
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. 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 fig. 1.)
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 fig. 2.)
The expected sources of payment 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 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.
section_title: Key Findings from the 2003 GAO Report on Emergency Department Crowding
paragraphs: In 2003, using three indicators that point to situations in which crowding is  likely occurring—diversion, 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.
section_title: Indicators of Emergency Department Crowding
paragraphs: Researchers use the indicators we reported on in 2003 to point to  situations in which crowding is likely occurring in emergency  departments. 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.
Researchers have developed a conceptual model to analyze the factors  that contribute to emergency department crowding and develop potential  solutions. 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 fig. 3.)
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).
section_title: According to Indicators, Emergency Department Crowding Continues
paragraphs: 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.
subsections: section_title: Hospitals Continue to Divert Ambulances
paragraphs: 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. (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. 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, compared to 1 in 10 hospitals in  nonmetropolitan areas. Some hospitals, however, reported that their  state or local laws prohibit diversion.
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. The results from these surveys show that  some hospitals reported going on diversion. 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 and  Maryland also found that diversion continues to occur and that the time  hospitals spent on diversion varied.
section_title: Wait Times Have Increased and in Some Cases Exceeded Recommended Time Frames
paragraphs: 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. Average wait  times also increased for patients in some acuity levels. (See fig. 4.) For  emergent patients, 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.
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. 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.
section_title: Boarding Continues to Be Reported, but National Data on Boarding Have Been Limited
paragraphs: 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. One article published in a peer-reviewed journal  reported that it is not unusual for critically ill patients to board in the  emergency department. 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. 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.
section_title: Articles and Officials Discussed the Effect of Crowding and Strategies for Decreasing Diversion, Wait Times, and Boarding
paragraphs: 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. 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.
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.
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.
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 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. 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.
section_title: Available Information Suggests Lack of Access to Inpatient Beds Is the Main Factor Contributing to Crowding, and Other Factors May Also Contribute
paragraphs: 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.
subsections: section_title: Articles and Subject- Matter Experts Have Reported a Lack of Access to Inpatient Beds as the Main Factor Contributing to Crowding
paragraphs: 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  reporting it was the main factor contributing to crowding. (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.
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. 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 show all 20 of the  most-prevalent diagnosis-related groups (DRG) 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.
section_title: Additional Factors Reported as Contributing to Crowding
paragraphs: 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.
subsections: section_title: Lack of Access to Primary Care
paragraphs: 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. 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.
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. 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. In addition, officials from AHRQ  noted that a larger proportion of patients using the emergency department  are insured than uninsured.
section_title: Shortage of Available On-Call Specialists
paragraphs: 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. 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. 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.
section_title: Difficulties in Transferring, Admitting, or Discharging Psychiatric Patients
paragraphs: 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. 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). 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.
section_title: Other Possible Factors That Contribute to Crowding
paragraphs: 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, 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.
section_title: Agency Comments and Our Evaluation
paragraphs: 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.
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section_title: Appendix I: Scope and Methodology
paragraphs: 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). We  analyzed available NCHS data for 2001 through 2006 on diversion and  wait times to determine what changes, if any, have occurred over time.  We analyzed wait time data by patient acuity level and hospital  characteristics, such as hospital ownership, metropolitan or  nonmetropolitan area location, and geographic region. 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, 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 to determine the diagnosis-related groups (DRG)  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. 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. 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.  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  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, 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.
section_title: Appendix II: Emergency Department Utilization, 2001 through 2006
paragraphs: 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 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).
section_title: Appendix III: Proposed Measures of Emergency Department Crowding
paragraphs: 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.
section_title: Appendix IV: Emergency Department Wait Times
paragraphs: 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.  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).
section_title: Appendix V: Comments from the Department of Health and Human Services
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: 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.