Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities
Published: 2003-03-14T00:00:00

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. Emergency departments report being under increasing pressure, with the number of visits nationwide increasing from an estimated 95 million in 1997 to an estimated 108 million in 2000. GAO was asked to provide information on emergency department crowding, including the extent hospitals located in metropolitan areas are experiencing crowding, the factors contributing to crowding, and the actions hospitals and communities have taken to address crowding. To conduct this work, GAO surveyed over 2,000 hospitals and about 74 percent responded. The survey collected information on crowding, such as data on diversion--that is, the extent to which hospitals asked ambulances that would normally bring patients to their hospitals to go instead to other hospitals that were presumably less crowded.
section_title: What GAO Found
paragraphs: While many emergency departments across the country reported some degree of crowding, the problem is more pronounced in certain hospitals and communities. For example, while 2 of every 3 hospitals reported asking ambulances to be diverted to other hospitals at some point in fiscal year 2001, a smaller portion--about 1 of every 10--reported being on diversion status for more than 20 percent of the year. Hospitals in areas with larger populations, areas with high population growth in recent years, and areas with higher-than-average percentages of people without health insurance reported higher levels of crowding. While no single factor stands out as the reason why crowding occurs, GAO found the factor most commonly associated with crowding was the inability to transfer emergency patients to inpatient beds once a decision had been made to admit them as hospital patients rather than to treat and release them. When patients "board" in the emergency department due to the inability to transfer them elsewhere, the space, staff, and other resources available to treat new emergency patients are diminished. Hospitals and communities reported a variety of actions to address crowding, including expanding their emergency departments and developing ways to transfer emergency patients to inpatient beds more efficiently. For the most part, these actions have not been extensively evaluated, so their effect is unknown. However, the widely varying characteristics between hospitals mean that no one approach is likely to emerge as a way to address this ongoing concern. Representatives from the American College of Emergency Physicians and the American Hospital Association and an independent reviewer provided comments on a draft of this report, 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. Emergency departments  report being under increasing pressure, with the number of visits  increasing about 14 percent from an estimated 95 million in 1997 to an  estimated 108 million in 2000, and the number of hospitals with emergency  departments decreasing by about 2 percent. This pressure has led to  reports of crowding. For example, considerable attention has been given  to reports that emergency departments request that ambulances that  would normally bring patients to their hospitals go instead to other  hospitals that are presumably less crowded—a practice known as  diversion. Crowded conditions in emergency departments can also lead to  long waits for care, which can prolong pain and suffering.
There are no standard measures of the extent to which emergency  departments are experiencing crowded conditions—hospital officials say  “they know it when they see it.” However, there are several indicators that,  according to experts, point to situations in which crowding is likely  occurring. One indicator is the number of hours a hospital is on diversion  status. A second indicator is the proportion of patients and the length of  time patients “board” or remain in the emergency department—and  therefore tie up space and staff resources—after a decision has been made  to admit them as inpatients or transfer them to other facilities rather than  releasing them. Finally, a third indicator is the proportion of patients who  leave the emergency department before receiving a medical evaluation,  generally because they tire of waiting.
While considerable attention has been focused on this topic, much of it  has centered on anecdotal reports or on data from a limited number of  communities or emergency departments. You asked us to determine if  data could be assembled from a broader, more national scope in order to  provide more perspective on the issue. We conducted a review that  encompassed hospitals located in the nation’s metropolitan statistical  areas (MSA). We excluded nonmetropolitan areas because available  information and contacts with rural health organizations indicated that  emergency department crowding is not a major problem in these areas.  Our work addressed the following questions:    To what extent are hospitals in MSAs experiencing crowded conditions in  their emergency departments, and is crowding more severe in some types  of MSAs than in others?
What factors contribute to emergency department crowding?     What actions have hospitals and communities taken to address crowding?
To conduct this work, we sent a mail questionnaire to all community  hospitals located in MSAs that reported having emergency departments in  2000—more than 2,000 hospitals in all, of which about 74 percent  responded. The survey collected information related to three indicators of  crowding: (1) the number of hours on diversion, (2) the percentage of  patients who were boarding in the emergency department for 2 hours or  more and the average number of hours boarded, and (3) the proportion of  patients who left before a medical evaluation. In analyzing these  responses, we weighted responses to adjust for a lower response rate from  investor-owned (for-profit) hospitals to provide estimates for the universe  of hospitals. To examine which factors contributed to crowding, we  analyzed information provided by the surveyed hospitals and other data on  hospital and MSA characteristics. To provide information on actions taken  by hospitals and communities to address crowding, as well as emergency  medical services (EMS) systems and diversion at the community level, we  conducted site visits in six locations where problems had been reported  regarding crowded emergency departments—Atlanta, Boston, Cleveland,  Los Angeles, Miami, and Phoenix. We selected these sites because they  varied in geographic location, proportion of people without health  insurance, population, and recent population growth. In these locations,  we interviewed EMS officials, professional associations, and hospital  officials, and we observed emergency departments in 24 hospitals. We  supplemented this work with analysis of existing national data and  reviews of relevant studies. We also interviewed persons knowledgeable  about the issues, including health services researchers; representatives  from hospital associations, provider associations, and emergency medical  associations; and federal, state, and local health officials. Appendix I  explains our methodology in more detail. We conducted our work from  July 2001 through February 2003 in accordance with generally accepted  government auditing standards.
subsections: section_title: Background
paragraphs: In 2000, about 3,900 nonfederal, general medical hospitals nationwide  reported providing emergency care in emergency departments. Of these,  just over half were located in MSAs. From 1997 through 2000, while the  number of emergency department visits increased about 14 percent, the  number of hospitals with emergency departments decreased by about 2  percent. The result was that the average number of visits per emergency  department increased by 16 percent. Many hospitals expanded the  physical space and number of treatment spaces in their emergency  departments during that time.
Recent reports have raised concern that many of the nation’s emergency  departments are experiencing high demand and crowded conditions. An  April 2002 report for the American Hospital Association, while limited in  scope and the proportion of hospitals responding, found that officials at  many hospitals in urban areas described their emergency departments as  operating at or above capacity. While there are no comprehensive studies  on the consequences of crowded conditions, health care researchers and  clinicians report that crowding has multiple effects, including prolonged  pain and suffering for some patients, long patient waits, increased  transport times for ambulance patients, inconvenience and dissatisfaction  for the patients and their families, and increased frustration among  medical staff. In addition to delays in treatment, some emergency  department directors have reported that patient care was compromised  and patients experienced poor outcomes as a result of crowded conditions  in emergency departments.
Because the medical conditions of patients who come to the emergency  department can range from mild injuries such as ankle sprains to serious  traumas such as from automobile accidents—and can also include patients  with chronic conditions such as asthma or diabetes—the space,  equipment, and medical personnel resources required to treat patients  vary. As a result, there are no specific criteria, such as a ratio of patients to  staff, to define when an emergency department is too crowded and its  providers are overloaded. Rather, emergency department administrators  and physicians say “they know it when they see it.” In the absence of  specific criteria to define when an emergency department is crowded,  health care researchers suggest using several available indicators to point  to crowded conditions. Based on our review of studies and discussions  with experts, we chose three indicators of emergency department  crowding. As shown in table 1, all three are useful indicators but all three  also have limitations.
subsections: section_title: Crowding Indicator 1: Diversion
paragraphs: One indicator of a crowded emergency department is the number of hours  a hospital is on diversionary status. Under federal law, all hospitals that  participate in Medicare are required to screen—and if an emergency  medical condition is present, stabilize—any patient who comes to the  emergency department, regardless of the individual’s ability to pay. Under  certain circumstances where a hospital lacks staffing or facilities to accept  additional emergency patients, the hospital may place itself on  “diversionary status” and direct en route ambulances to divert to another  hospital. In general, hospitals ask EMS providers to divert ambulances to  other medical facilities because their emergency department staff are  occupied and unable to promptly care for new arrivals or specific services  within the hospitals, such as the intensive care units, are filled and unable  to accommodate the specialized needs of new ambulance arrivals.
While on diversion, hospitals must still treat any patients who arrive by  ambulance, and in some cases, local community protocols allow  ambulances to go to a hospital that is on diversion when the patient asks  to go to that hospital or if the patient needs immediate medical treatment.  In addition, even while on diversion, the emergency department is still  required to screen and treat nonambulance patients—those patients who  walk in or otherwise arrive at the hospital—and these patients make up  the vast majority of visits to the emergency department. The Department  of Health and Human Service’s (HHS) National Center for Health Statistics  estimates that in 2000 about 14 percent of emergency department visits  were made by patients who arrived by ambulance, while 78 percent of  visits were made by patients who arrived at the emergency department by  “walking in.” For the remaining visits, the patients were brought in by the  police or social services (1.5 percent), or the mode of arrival was unknown  (6.3 percent).
As a measure of crowding, diversion has limitations in that some hospitals,  even when crowded, do not have the option to divert ambulances due to  state or local regulations, because there are no other medical facilities  nearby, or because of individual hospital policies. Hospital practices may  vary regarding the threshold at which a hospital goes on diversion. Local  community or hospital policies may also differ regarding the length of time  a hospital may remain on diversion. (See app. II for the local community  policies for the six sites we visited). However, for those hospitals that can  go on diversion, it is an indicator of how often these emergency  departments believe they can no longer handle additional ambulance  patients.
section_title: Crowding Indicator 2: Boarding
paragraphs: A second indicator suggested by health care researchers is the number of  patients who are “boarding” in the emergency department. These patients  remain in the emergency department after the decision has been made to  admit them to the hospital or transfer them to another facility. Many  factors can contribute to the length of time a patient is boarded in the  emergency department, such as inpatient bed availability, staffing levels,  and the complexity of a patient’s condition. Regardless of the reason,  while waiting for an inpatient bed or transfer, these patients still require  care and take up treatment space, equipment, and staff time in the  emergency department, shrinking the department’s resources available to  treat other emergency patients. A limitation of using boarding as an  indicator is that many hospitals do not collect this information regularly  and can only estimate how often and how long patients board in their  emergency departments. In addition, it is possible that emergency  departments board patients while also having available treatment spaces  to see additional patients.
section_title: Crowding Indicator 3: Leaving before a Medical Evaluation
paragraphs: Finally, the proportion of patients who leave after triage but before  receiving a medical evaluation is another indicator suggested by health  care researchers that could indicate a crowded emergency department.  Long waits in the emergency department can delay needed care and  contribute to an increase in the number of people who choose to leave the  emergency department before receiving a medical evaluation. A limitation  to this indicator is that, because emergency department staff triage  patients, those with nonemergent conditions generally wait the longest  and may be most likely to tire of waiting and leave before a medical  evaluation. However, relatively mild conditions could potentially become  more serious if patients do not receive needed medical care because they  leave the emergency department before being evaluated and treated. A  study of the consequences of leaving the emergency department prior to a  medical evaluation at one public hospital found that 46 percent of those  who left were judged to need immediate medical attention, and 11 percent  who left were hospitalized within the next week.
section_title: Emergency Department Crowding Is More Pronounced in Some Hospitals and Certain Types of Communities
paragraphs: Although most emergency departments across the country reported some  degree of crowding on one or more of the three indicators, the problem is  much more pronounced in some hospitals than in others. In addition,  hospitals in the largest metropolitan areas (those with populations of 2.5  million or more), communities with high population growth, and  communities with above average percentages of people without health  insurance had higher levels of crowding.
subsections: section_title: Indicators Show Varying Degrees of Crowding Nationwide
paragraphs: Analysis of responses to our nationwide survey showed substantial  variation in the degree of crowding reported across all three indicators— diversion, boarding, and patients leaving before a medical evaluation.  Hospitals ranged from little or no crowding to crowding that persisted for  a substantial part of the time.
Diversion. In total, we estimate that about 2 of every 3 of the hospitals in  our survey universe went on diversion at least once during fiscal year  2001. We estimate that about 2 in every 10 of these hospitals were on  diversion for more than 10 percent of the time, and about 1 in every 10 was  on diversion for more than 20 percent of the time—or about 5 hours per  day. Figure 1 shows the variation in the amount of diversion reported by  hospitals in MSAs.
Diversion varies greatly by MSA. Figure 2 shows each MSA and the share  of hospitals within the MSA that reported being on diversion more than 10  percent of the time—or about 2.4 hours or more per day—in fiscal year  2001. Of the 248 MSAs for which data were available, 171 (69 percent)  had no hospitals reporting being on diversion more than 10 percent of the  time. By contrast, 53 MSAs (21 percent) had at least one-quarter of  responding hospitals on diversion for more than 10 percent of the time.
Boarding. Boarding patients for 2 hours or more in the emergency  department while waiting for an inpatient bed or transfer occurred to  some extent at an estimated 9 of every 10 hospitals. As part of our survey,  we examined what percentage of emergency patients who boarded spent 2  hours or more in boarding status and the average number of hours  patients boarded. As figure 3 shows, while many hospitals reported  boarding less than 25 percent of boarded patients for 2 hours or more in  the past 12 months, about one-third of them reported boarding 75 percent  or more of their boarded patients for that long. About 1 in every 5  hospitals reported an average boarding time in their emergency  departments of 8 hours or more.
Boarding varies greatly by MSA. Figure 4 shows each MSA and the extent  to which responding hospitals within the MSA reported that of those  patients who boarded in the past 12 months, at least half spent 2 hours or  more in boarding status, and the average boarding time was 8 hours or  more. Of the 206 MSAs for which data were available on the percentage of  patients boarded and the average number of hours boarded, 112 MSAs  (54 percent) had no hospitals reporting that they met these criteria. In  contrast, 52 of the 206 MSAs (25 percent) had at least one-fourth of  responding hospitals reporting that they boarded at least half of their  patients for 2 hours or more and had an average boarding time of at least 8  hours.
Patients Leaving before a Medical Evaluation. From our nationwide survey  of hospitals, we estimate that the median percentage of patients who left  after triage but before a medical evaluation in fiscal year 2001 was 1.4  percent. We estimate that about 39 percent of hospitals had from 1 to 3  percent of patients who left before medical a evaluation in fiscal year 2001  while about 7 percent of hospitals reported that 5 percent or more of  emergency department patients left before a medical evaluation (see fig.  5).
Figure 6 shows each MSA and the extent to which hospitals within the  MSA reported at least 5 percent of patients leaving before a medical  evaluation. Of the 243 MSAs for which data were available on the  percentage of patients who left before a medical evaluation, 183 MSAs  (75 percent) had no hospitals reporting that they met these criteria. In  contrast, 31 of the 243 MSAs (13 percent) had at least one-fourth of  responding hospitals reporting that at least 5 percent of patients left  before a medical evaluation in fiscal year 2001.
section_title: Crowding More Pronounced in Certain Types of Communities
paragraphs: We analyzed our three crowding indicators across different MSA  characteristics, including population, population growth, and level of  uninsurance. We found all three characteristics were associated with  reported levels of crowding.
subsections: section_title: MSAs with Larger Populations
paragraphs: Hospitals in MSAs of 2.5 million or more people reported higher levels of  all three indicators—diversion, boarding, and patients leaving before a  medical evaluation—than hospitals in MSAs of less than 1 million people  (see table 2). In these larger areas, hospitals had a median of about 162  hours of diversion in 2001 compared with 9 hours for hospitals in areas  with a population of less than 1 million. Similarly, the median percentage  of patients boarding 2 hours or more was more than twice as high in large  MSAs—48 percent versus 23 percent. The median percentage of patients  who left before a medical evaluation was also higher, though not as  dramatically as for the two other indicators.
Our site visits show that crowding indicators vary not only across MSAs  but also between hospitals within MSAs. Four of the six locations we  visited (Atlanta, Los Angeles, Boston, and Phoenix) were in MSAs with  populations of over 2.5 million and we found variation among hospitals  within these communities. For example, the 10 major Boston hospitals  were on diversion for an average of 322 hours in 2001. However, 2 of the  10 hospitals accounted for nearly half of the diversion hours for the 10  hospitals, averaging nearly 800 hours of diversion each.
section_title: MSAs with High Population Growth
paragraphs: Hospitals in communities with high population growth from 1996 through  2000 reported higher levels of diversion and patients leaving before a  medical evaluation compared to hospitals in communities with lower  population growth (see table 3). The median number of hours of diversion  in fiscal year 2001 for hospitals in MSAs with a high percentage population  growth was about five times that for hospitals in MSAs with lower  percentage population growth. Similarly, the median percentage of  patients who left before a medical evaluation was significantly higher for  hospitals in MSAs with high population growth—1.7 percent—than for  those in MSAs with low population growth—1.0 percent. In addition, of  hospitals that reported at least 5 percent of patients leaving before a  medical evaluation in 2001, 31 percent were in communities with high  population growth compared to 15 percent in communities with low  population growth.
Two of the six locations we visited, Atlanta and Phoenix, were in MSAs  with high population growth from 1996 to 2000—16 percent and 18 percent  growth, respectively. Diversion hours varied among hospitals in these  communities. For example, in Phoenix, 5 of the 28 hospitals in the region  made up about 42 percent of the region’s diversion hours in 2001. Two of  these 5 hospitals with high rates of diversion were in the city’s central  sector. Hospitals in this sector were on diversion an average of 10 percent  of the time in 2001. By contrast, hospitals in the region’s northeast sector,  a more suburban area, had the lowest average rate of diversion—an  average of 3 percent of the time.
section_title: MSAs with Higher Levels of Uninsurance
paragraphs: Hospitals in communities with a higher percentage of people without  health insurance reported higher levels of diversion and patients leaving  before a medical evaluation (see table 4). For example, hospitals in MSAs  where the percentage of uninsured people was above average reported  having almost twice as many patients leave the emergency department  prior to a medical evaluation than those in MSAs where the percentage of  uninsured was below average. Our analysis of other national data indicate  that waiting times, which are reported to be the primary reason patients  leave the emergency department before a medical evaluation, were longer  in communities with more uninsured people. For example, in 2000, waiting  times for nonemergent visits averaged about 25 minutes longer in  communities with high levels of uninsured people than in communities  with low levels of uninsured people (90 minutes versus 65 minutes).
Of the six sites we visited, three (Los Angeles, Phoenix, and Miami) were  MSAs with significantly higher percentages of people without health  insurance. The crowding indicators varied among hospitals in these MSAs  with high levels of uninsurance. For example, the number of hours on  diversion in 2001 for hospitals in the Los Angeles MSA ranged from no  diversion at four hospitals to 6,186 hours—about 71 percent of the time— at another hospital.
section_title: Crowding More Pronounced in Certain Types of Hospitals
paragraphs: We also analyzed differences across a wide range of hospital  characteristics, including the number of staffed beds; hospital ownership;  teaching status; trauma center status; and the proportions of emergency  department visits covered by Medicare, Medicaid or the State Children’s  Health Insurance Program (SCHIP), or self-pay as the payer source. All  three indicators of crowding were significantly higher in hospitals with  more staffed beds and at teaching hospitals, while the median numbers of  hours on diversion were higher at hospitals designated as certified trauma  centers and at hospitals with fewer patients covered by Medicare. In  addition, we found that the median proportion of patients who left before  a medical evaluation was significantly higher in public hospitals than  private, not-for-profit hospitals, and in hospitals with more emergency  department visits covered by Medicaid and SCHIP or more patients who  were self-pay patients. (See app. III for additional information on the  indicators of crowding by select hospital characteristics).
section_title: Availability of Inpatient Beds for Emergency Patients Cited as a Key Factor Contributing to Crowding, but Other Factors Also Contribute
paragraphs: No single factor stands out as the reason why crowding occurs. Rather, a  number of factors, including many outside the emergency department, are  associated with crowding. In both the opinion of hospitals we surveyed  and of hospital officials we interviewed, the factor most commonly  associated with crowding was the inability to transfer emergency patients  to inpatient beds once decisions had been made to admit them as hospital  patients rather than to release them after treatment. In looking at why  hospitals did not have the capacity to always meet the demand for  inpatient beds from emergency patients, hospital officials, researchers,  and others pointed to (1) financial pressures leading to limited hospital  capacity to meet periodic spikes in demand for inpatient beds and   (2) competition between admissions from the emergency department and  scheduled admissions such as surgery patients, who are generally  considered to be more profitable. Other factors cited as contributing to  crowding include closures of nearby hospitals or availability of physicians  and other providers in the community.
subsections: section_title: Lack of Available Inpatient Beds for Emergency Patients the Most Commonly Cited Factor
paragraphs: The inability to transfer emergency patients to inpatient beds was the  condition that surveyed hospitals reported most often as contributing to  going on diversion and boarding patients. Even when treatment spaces are  available in the emergency department, hospitals may go on diversion for  patients who will likely need instrument-monitored beds or critical care  beds because these types of beds are full. As figure 7 shows, the most  common types of beds that were unavailable were intensive care unit  (ICU) or critical care unit (CCU) beds, followed by instrument-monitored  (telemetry) beds. More than three-fourths of hospitals that went on  diversion reported that the lack of ICU/CCU beds contributed to diversion  to a moderate, great, or very great extent.
Similarly, lack of inpatient beds was the dominant reason given for the  need to board patients in the emergency room (see fig. 8). Of hospitals that  boarded patients for 2 hours or more in the past 12 months, about 80  percent cited the lack of telemetry or critical care beds as contributing to  boarding to a moderate, great, or very great extent.
Our analysis of data collected in our survey generally corroborates that a  lack of inpatient beds plays a major role in contributing to emergency  department crowding. We found that those hospitals in communities with  higher demand for inpatient beds—as measured by admissions per  inpatient bed—had higher indicators of crowding. As table 5 shows,  hospitals that rank in the top 25 percent in terms of admissions per bed in  the MSA had both significantly higher numbers of diversion hours and  proportions of patients boarding 2 hours or more than hospitals in the  bottom 25 percent of admissions per bed. For example, hospitals in the  top 25 percent reported a median of 170 hours on diversion in fiscal year  2001, compared with a median of 12 hours for hospitals in the lowest 25  percent.
Similarly, hospitals with more demand for inpatient beds from the  emergency department—that is, a higher proportion of emergency visits  resulting in hospital admission—also had higher indicators of crowding.  As table 6 shows, the quarter of hospitals with the highest percentages— more than 19.7 percent—of emergency visits resulting in inpatient hospital  admission reported more diversion and boarding than the quarter of  hospitals with the smallest percentages—less than 11.8 percent—of  emergency visits resulting in admission.
Finally, our analysis found that hospitals with more patients per bed— measured by the average occupancy in fiscal year 2001 as a percentage of  the total number of staffed inpatient beds on the last day of the fiscal  year—also had higher indicators of crowding in the emergency  department (see table 7).
The conclusion that the availability of inpatient beds contributes to  crowding in emergency departments was reiterated at the hospitals we  visited on our site visits. At 19 of the 24 hospitals we visited, hospital  officials reported that the lack of inpatient beds and subsequent boarding  of emergency patients was a key factor contributing to crowding. In  addition, a 1-week survey conducted in Massachusetts found that  hospitals’ occupancy rates were higher when hospitals were on diversion.
section_title: Several Reasons Cited for Hospitals Not Always Having Inpatient Capacity to Meet Demand for Beds from Emergency Patients
paragraphs: When we examined why hospitals did not always have the inpatient  capacity to meet the demand for beds from emergency patients, hospital  administrators, researchers, and clinicians cited several reasons, including  (1) financial incentives to control costs and maximize revenue by staffing  inpatient beds at a point where they will nearly always be full—a practice  that limits a hospital’s ability to meet periodic spikes in demand, and   (2) competition between emergency department admissions and  scheduled admissions for available beds.
subsections: section_title: Economic Factors Influence Hospitals’ Capability to Meet Periodic Spikes in Demand
paragraphs: One reason reported for the lack of inpatient beds was the financial  pressures hospitals face to staff inpatient beds at a level where they will  nearly always be full. This practice limits a hospital’s ability to meet  periodic spikes in demand. Hospital administrators, clinicians, and health  care researchers report that changes in the hospital economic climate  have contributed to this decline in “surge capacity.” For example, in a  report prepared for the Massachusetts Health Policy Forum, one health  policy researcher noted that the lower occupancy rates of the 1970s and  1980s became unacceptable in the 1990s when hospitals were increasingly  driven by market-based factors. In a market-based system, successful  hospitals run full, attract both elective and emergency patients, and are  staffed closer to average demand than to the peaks.
Another factor sometimes cited that is related to insufficient bed capacity  involves staffing. Officials at some hospitals we visited said that they did  not staff more of the beds they already had or open new beds because they  were concerned they would not be able to staff them or could not afford  the cost of staffing them. These hospitals cited the costs and difficulties  recruiting nurses, particularly the cost of hiring nurses from agencies that  contract out nursing services. For example, officials at a Miami hospital  we visited that staffed only about two-thirds of the beds for which it was  licensed in 2001 said that they would lose money if they staffed more beds  because of the cost of contract nurses.
section_title: Emergency Department Admissions Compete with Other Admissions
paragraphs: For the inpatient beds that are available, many researchers and hospital  officials we interviewed reported that hospitals often balance admissions  from emergency departments with scheduled admissions for surgical  procedures, which are generally considered more 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 pneumonia, rather than for those procedures that are considered  more profitable. Available data from the Agency for Healthcare Research  and Quality’s (AHRQ) Healthcare Cost and Utilization Project, Nationwide  Inpatient Sample, show that of hospital admissions from the emergency  department in 2000, most were for medical conditions (such as pneumonia  and heart failure). Further, 19 of the 20 most prevalent diagnosis related  groups (DRG) for these admissions were for medical conditions. In  contrast, half of the 20 most common DRGs for admissions that were not  from the emergency department were for surgical procedures (such as  orthopedic surgery and cardiac pacemaker implantation).
Many hospital officials and researchers also said that emergency  department patients are less profitable because a larger proportion of  emergency admissions are patients for whom the primary payer source is  self-pay, which includes the uninsured, or Medicaid, which is generally  considered to provide lower reimbursement. As shown in figure 9,  available data from AHRQ’s Healthcare Cost and Utilization Project show  that the proportion of admissions for uninsured patients or patients with  Medicaid as the primary payer source was higher for admissions from the  emergency department than for routine admissions in 2000. At the same  time, the proportion of admissions with private insurance as the primary  payer source was higher for routine admissions than for patients admitted  from the emergency department. Because self-pay patients and those  covered by Medicaid are viewed as providing lower reimbursement,  hospital officials and health care researchers said that hospitals have a  financial incentive to fill the limited number of available beds with  scheduled admissions rather than emergency department admissions.
In addition, some hospital officials reported that surgeons bring in  business that generates revenues for the hospital and that hospitals may  not want to cancel or reschedule elective surgeries—and disrupt their  surgeons and patients—in order to make beds available for emergency  department patients. This point was supported by our survey results—less  than one-third of hospitals that went on diversion in fiscal year 2001 (29  percent) reported that they had canceled any elective procedures to  minimize going on diversion.
section_title: Additional Factors Cited as Contributing to Crowding
paragraphs: Hospital officials reported in both our survey and during our site visits that  other factors contributed to crowding as well, including increased demand  due to the closure of other hospitals and difficulties in accessing  physicians and other medical providers in the community. For example,  officials at one hospital we visited said that when two neighboring  hospitals closed in 1999 and 2000, their hospital experienced a significant  increase in emergency department visits and subsequent crowding. In  addition, officials at some of the hospitals we visited said they thought that  the availability of physicians and other services, such as psychiatric  services, in their communities affected crowding in one or more instances.  For example, in Cleveland, the county psychiatric mobile health unit  recently stopped taking patients in the late evening and on weekends,  increasing the amount of time the emergency department had to care for  psychiatric patients during those times. One Cleveland hospital we visited  reported that boarding times for patients awaiting assessment by this unit  had increased for patients who arrived late at night.
section_title: Wide Range of Activities Under Way to Manage Crowding at Hospitals and in Communities, but Problems Persist
paragraphs: At the six sites we visited, actions to address emergency department  crowding had been taken at both the hospital and community levels. Steps  taken by hospitals generally fell into two categories: (1) increasing  capacity and (2) improving the efficiency with which patients are  treated—and if necessary, moved to inpatient beds. At the community  level, EMS agencies, health care associations, and public agencies were  generally active to some degree in implementing communitywide policies  and computerized diversion tracking systems to help direct the flow of  ambulance traffic and keep hospital staff and EMS providers informed  about which hospitals are on diversion. While hospital and community  officials reported some positive results for their efforts, they generally  described these efforts as attempts to manage crowding problems rather  than to substantially reduce them. The effects of these efforts have not  been widely studied, though several activities are now under way that may  help facilitate future evaluations.
subsections: section_title: Hospitals Expand Capacity and Increase Efficiency
paragraphs: Data from the National Center for Health Statistics for 1992 to 2000 also showed that the  percentage of emergency department visits admitted to the hospital had not changed  significantly—about 12 percent of visits resulted in admissions in 2000. However, the same  data found that the percentages of emergency department visits referred to another  physician or clinic or with no follow-up planned had increased significantly to about 47  percent and 10 percent of visits, respectively, in 2000.
Although officials at several hospitals we visited reported that difficulty getting specialty  coverage for the emergency department may contribute to longer patient stays in the  emergency department while waiting for specialists to evaluate their condition, most  hospitals we surveyed did not believe that this problem contributed to crowding to a great  extent. While our survey found that 59 percent of hospitals reported problems with on-call  specialty coverage, only about 5 percent of hospitals that went on diversion reported that  lack of on-call specialty coverage contributed to diversion to a moderate, great, or very  great extent, and only 7 percent of hospitals that boarded patients reported that problems  with on-call coverage contributed to boarding to a moderate, great, or very great extent. department patients to building new, larger emergency departments.  Some hospitals added a unit—often referred to as a fast-track unit—to the  emergency department that is staffed with appropriate personnel, such as  nurse practitioners and physician assistants, to quickly treat nonurgent  cases. In addition, officials at 11 of the 24 hospitals we visited told us that  their hospitals had expanded or would be expanding inpatient capacity or  building new hospital facilities, a step that could make it easier to transfer  patients who need to be admitted as inpatients. We found expansions or  planned expansions at different types of hospitals, including not-for-profit,  public, and for-profit hospitals. At some hospitals that had recently  expanded their capacity, hospital officials reported that even though the  expansion helped, they continue to experience very crowded conditions.  Table 8 provides examples of the kinds of actions taken or planned at the  hospitals we visited.
While more than two-thirds of the hospitals we visited were expanding or  reported having plans to expand their capacity, nearly all of the 24  hospitals we visited reported taking some type of action to increase the  flow of patients through the emergency department and to reduce the time  needed to place admitted emergency department patients into hospital  beds. When patients cannot be moved efficiently through the emergency  department and into inpatient hospital beds, they occupy emergency  department space, staff, and services and reduce the capacity that might  otherwise be available to treat other patients waiting to be seen in the  emergency department. As shown in table 9, hospitals’ approaches to  increase efficiency varied. For example, some hospitals focused on  increasing the speed of the registration and triage process, while others  were dependent on actions taken outside of the emergency department  and on inpatient floors of the hospital, such as having coordinating  committees or multidisciplinary teams that are directed to increase  availability of inpatient beds and reduce boarding.
section_title: Community Activities Focus on Systems to Manage Diversion
paragraphs: At the community level, efforts focused on ways to better manage  crowding, particularly diversion, through task forces and development of  diversion policies and tracking systems. At three of the six sites we visited,  task forces had been formed to address these issues. The task forces  generally addressed crowding and diversion in three ways: assembling  stakeholders to examine causes, bringing attention to the issue, and  developing methods to manage the problem (see table 10).
Five of the six sites we visited had developed standard policies or  guidelines regarding diversion and operated or participated in electronic  systems for tracking ambulance diversion. The sixth site we visited— Miami-Dade County—took a different approach. The largest EMS provider  in the area, the Miami-Dade Fire Rescue Department EMS Division, no  longer formally honors hospital requests for diversion. On March 31,  1999, this EMS agency implemented a new policy directing ambulances to  bring patients to the nearest appropriate hospital, citing concerns over the  increased number of hospital emergency room closures and a  compromised ability to deliver quality patient care.
For the five sites we visited that allowed diversion, each system improved  communication among hospital and EMS providers by (1) allowing  hospitals to request being put on diversion, (2) making hospitals aware of  other hospitals’ diversion status, and (3) making ambulance dispatchers  and ambulance drivers aware of which hospitals are on diversion. In these  locations, diversion systems are used to provide a structure to  systematically try to spread the ambulance volume during times of peak  demand by redirecting ambulances to hospitals that are presumably less  crowded. At three of these sites, EMS agencies produce reports on the  number of hours each hospital was on diversion each month. EMS  agencies, hospital associations, and government agencies use diversion  reports to review policies and monitor hospitals’ diversion hours.
section_title: Current Efforts Unable to Reverse Crowding Trends
paragraphs: While some sites we visited have experienced limited improvement, efforts  under way have not made substantial reductions in the current extent of  crowding. Some officials we interviewed described their efforts as  attempts to manage the situation to keep it from getting worse rather than  solving the problem. For example, in Boston, officials from the  Massachusetts chapter of the American College of Emergency Physicians  who participate in their state’s diversion task force said they see diversion  as a Band-Aid for addressing what they believe is a crisis. They said that  while the task force has taken steps to better manage diversion, increased  demand for emergency department services due to events such as a bad  flu season or disaster could still tax the system beyond its capacity.
Community-level data tend to support the view that these efforts, while  perhaps helping to mitigate crowding, are not reversing the recent trends  in crowding. For example, from 2000 through 2001, the three sites we  visited that produce regular reports on diversion all experienced increases  in the percentage of time that their hospitals were on diversion. The  increase in the hours of diversion in these three locations ranged from 39  percent in the Los Angeles region to 73 percent in the Boston region.
section_title: Studies Assessing Impact of Current Efforts Have Been Limited but Other Activities Are Under Way
paragraphs: Despite the number of steps that hospitals and communities have taken,  few studies have been conducted on the effects of hospitals’ and  communities’ efforts to address crowding. Only 1 of the 24 hospitals we  visited reported having completed an evaluation of the impact of its  activities. This hospital had implemented a program to increase efficiency  by discharging patients by noon and reported that its efforts resulted in  earlier placement of admitted emergency department patients in inpatient  beds. At the community level, while several communities monitor the  number of hours on diversion, they reported that no comprehensive  evaluations have been completed on the impact of communitywide efforts  to address crowding.
Recent initiatives have been started by such organizations as the Joint  Commission on Accreditation of Healthcare Organizations, AHRQ, and the  Robert Wood Johnson Foundation that may help in future evaluations of  crowding. These organizations have initiatives under way to further study  crowding, develop hospital standards related to crowding, develop and  test measures of crowding, provide technical assistance to hospitals, and  evaluate potential steps to ease the problem. However, the results of these  studies are not anticipated to be available until later in 2003 or 2004.
section_title: Concluding Observations
paragraphs: Emergency department crowding is not an issue that can be solved in the  emergency department alone. Rather, it is a complex issue that reflects the  broader health care market. It is clear that, as a key part of the health care  safety net, emergency departments in many of the nation’s largest  communities are under strain.
Our work suggests that some aspects of the problem are hospital-specific,  such as high numbers of emergency patients, lack of space, and delays in  obtaining test results. In addition, crowding appears to reflect the inability  of individual hospitals to meet the demand for inpatient beds, particularly  critical care and telemetry beds, both from emergency patients who need  to be admitted to the hospital and patients admitted for elective  procedures. When hospitals cannot accommodate peaks in demand, either  because they lack space or because they choose to operate at levels that  allow little excess capacity, the result is that emergency departments will  often board patients who are waiting for inpatient beds. When they do, the  capacity of the emergency department to treat additional patients is  diminished.
While such issues as concerns about staffing inpatient beds and  availability of other providers in the community are similar across  communities, the solutions may differ by community and local health care  market. For example, one community may face crowding in the emergency  department largely because people have problems accessing physicians  and other providers in the community, and potential solutions could  involve steps to improve access to these other providers or establishing  fast-track systems to treat nonurgent conditions in the emergency  department. Another community may face crowding primarily because  facilities have closed or populations have increased and there are too few  hospital beds staffed and operated in the area. In this situation, the  solution could involve reopening beds in existing facilities that were not  set up and staffed. To address communitywide factors contributing to  crowding, hospitals may need to work collaboratively with other facilities  in their communities. Communitywide efforts such as task forces and  standardized procedures and diversion policies have improved  communications between hospitals and EMS providers and provided some  degree of sharing the load when multiple hospitals are crowded. However,  these efforts appear to only manage the problem of crowded conditions in  emergency departments, rather than eliminate it.
Adding capacity, for both the emergency departments and for inpatient  beds, has been suggested as a solution, but no one solution is likely to fit  all circumstances. Crowding is clearly worse in some communities and  hospitals than in others, and the specific reasons for crowding need to be  better understood, particularly at the local level.
section_title: Comments from External Reviewers
paragraphs: Representatives from the American College of Emergency Physicians and  American Hospital Association and an independent reviewer provided  comments on a draft of this report. The American College of Emergency  Physicians stated that our methodology was comprehensive and  systematic and identified and documented the leading causes of  emergency department crowding. It also stated that while the crowding  problems may be more pervasive in large metropolitan areas, its members  had provided recent anecdotal information that indicates that the  crowding problem is now becoming a concern in rural areas. While it is  possible that some rural areas are becoming concerned about crowding,  our survey was limited to hospitals in MSAs because available information  and contacts with rural health organizations indicated that emergency  department crowding was not a major problem in these areas.
An independent reviewer who has conducted research on emergency  department crowding issues stated that the report was well done and  informative. This reviewer and the American Hospital Association  provided technical comments that we incorporated as appropriate.
As we agreed with your office, unless you publicly announce the contents  of this report earlier, we plan no further distribution of it until 14 days  from the date of this letter. We will then send copies to others who are  interested and make copies available to others who request them. In  addition, this report will be available at no charge on GAO’s Web site at  http://www.gao.gov.
If you or your staff have any questions, please contact me at (202) 512- 7119. An additional GAO contact and the names of other staff members  who made major contributions to this report are listed in app. IV.
section_title: Appendix I: Scope and Methodology
paragraphs: To accomplish our objectives, we surveyed over 2,000 short-term  nonfederal, general medical and surgical hospitals with emergency  departments located in metropolitan statistical areas (MSA). These  hospitals are located in the 50 states and the District of Columbia. We  obtained and analyzed data using three indicators of emergency  department crowding: diversion, boarding, and patients who left before  receiving a medical evaluation. We also used several hospital and  community characteristics, including hospital ownership, admissions per  bed, community population and growth, and the proportion of patients in  the community without insurance. In addition, we visited six metropolitan  areas—Atlanta, Boston, Cleveland, Los Angeles, Miami, and Phoenix. In  these locations, we interviewed emergency medical services officials and  officials at 4 hospitals in each area, for a total of 24 hospitals. We also  interviewed (1) federal agency officials at the Department of Health and  Human Services’ (HHS) National Center for Health Statistics, Health  Resources and Services Administration, and Agency for Healthcare  Research and Quality (AHRQ), (2) health care researchers at organizations  such as the Council on Health Care Economics and Policy, the Robert  Wood Johnson Foundation, and the Joint Commission on Accreditation of  Healthcare Organizations, (3) representatives of national and local  professional associations such as the American Ambulance Association,  American Hospital Association, American College of Emergency  Physicians, Emergency Nurses Association, National Association of  Emergency Medical Services Physicians, and American Medical  Association, and (4) hospital administrators and clinicians. In addition, we  reviewed relevant studies and policy documents and analyzed information  from national databases, including HHS’s National Center for Health  Statistics’ National Hospital Ambulatory Medical Care Survey and AHRQ’s  Healthcare Cost and Utilization Project, and the Health Resources and  Services Administration’s Area Resource File. We conducted our work  from July 2001 through February 2003 in accordance with generally  accepted government auditing standards.
subsections: section_title: Survey of Hospitals
subsections: section_title: Survey Universe and Development
paragraphs: To address questions about the extent of diversion, boarding, and patients  leaving before a medical evaluation at hospitals in MSAs, we mailed a  questionnaire to all 2,041 short-term, nonfederal, general medical and  surgical care hospitals that reported they had emergency departments and  were located in MSAs in the 50 states and the District of Columbia based  on data from the American Hospital Association’s Annual Survey  Database, Fiscal Year 2000. We mailed the questionnaires to the chief  administrator of each hospital in May 2002. Each hospital was asked to  report for the emergency department located at its main campus.
The survey included questions on the emergency department, such as   (1) whether the hospital went on diversion and, if so, the number of hours  on diversion in the hospital’s fiscal year 2001, (2) whether the hospital  boarded patients for 2 hours or more in the past 12 months and, if so, the  percentage of boarded patients who boarded 2 hours or more and the  average number of hours boarded, and (3) the number of emergency  department visits and the number of patients who left after triage but  before a medical evaluation in the hospital’s fiscal year 2001. It also  included questions on the general hospital, including the number of staffed  beds (excluding long-term care, labor and delivery, and postpartum beds)  as of the last day of the hospital’s fiscal year 2001. In developing these  questions, we reviewed the literature and prior surveys related to  crowding issues and conducted discussions with expert researchers. We  also pretested our questionnaire in person with officials at 10 hospitals  and refined the questionnaire as appropriate.
section_title: Response Rates
paragraphs: Of the initial universe of 2,041 hospitals, 18 had closed by 2002 and 2 did  not have emergency departments in fiscal year 2001, resulting in a final  universe of 2,021 hospitals. We conducted follow-up mailings and  telephone follow-up calls to nonrespondents. We obtained responses from  1,489 hospitals, for an overall response rate of about 74 percent.
section_title: Survey Analysis
paragraphs: We analyzed the response rates from various categories of hospitals and  weighted responses to adjust for a lower response rate from investor- owned (for-profit) hospitals so that our results would reflect the  nationwide mix of hospital types. We analyzed the information provided  by hospitals for three indicators of emergency department crowding— diversion, boarding, and patients who left before a medical evaluation. In  many cases, hospitals provided estimates for these indicators. Specifically,  we estimate that (1) of hospitals that went on diversion, about 45 percent  provided estimates for the number of hours on diversion in fiscal year  2001, (2) of hospitals that boarded patients for 2 hours or more in the past  12 months, about 74 percent provided estimates for the percentage of  patients boarding 2 hours or more and about 74 percent provided  estimates for the average number of hours patients boarded, and (3) about  34 percent of all hospitals provided estimates of the number of patients  who left after triage but before a medical evaluation. For those hospitals  that provided estimates, we used these estimates in our analyses.
We examined the extent of crowding in hospitals in MSAs, by different  MSA and hospital characteristics. We grouped MSAs by characteristics  such as U.S. Census Bureau population in 2000, population growth from  1996 to 2000, and the percentage of the population without health  insurance. We examined our indicators of crowding by hospital  characteristics such as the number of staffed beds on the last day of fiscal  year 2001; whether the hospital was public, private not-for-profit, or  investor-owned (for-profit); the hospital’s teaching status; whether it was a  certified trauma center; and the proportion of emergency department  visits covered by Medicare, Medicaid and the State Children’s Health  Insurance Program, and self-pay as the payer source. We compared the  medians of our three indicators of crowding across these characteristics.  In calculating the median number of hours on diversion and the median  percentage of patients boarding 2 hours or more, we considered hospitals  that did not go on diversion in fiscal year 2001 to have no hours of  diversion and hospitals that did not board any patients 2 hours or more to  have no percentage of patients boarding.
We also conducted analyses to determine key factors associated with  these indicators of crowding. We analyzed hospitals’ responses regarding  which key factors contributed to our indicators of crowding and examined  the medians for the crowding indicators grouped by admissions per bed in  the MSA, percentage of emergency visits resulting in hospital inpatient  admissions in fiscal year 2001, and the average daily census as a  percentage of the number of staffed beds in the hospitals’ fiscal year 2001.  In addition, we analyzed data from AHRQ’s Healthcare Cost and  Utilization Project, Nationwide Inpatient Sample, 2000, on the payer  source of admissions.
section_title: Site Visits
paragraphs: We conducted site visits in six locations: Atlanta, Georgia; Boston,  Massachusetts; Los Angeles, California; Cleveland, Ohio; Miami, Florida;  and Phoenix, Arizona. We selected the six sites judgmentally to include  locations that varied in geographic location, the proportion of people  without health insurance, MSA population, and recent population growth  (see table 11). In addition, media reports and other sources had indicated  that all six sites had reported problems with crowded emergency  departments.
At the six locations, we visited four hospitals at each site (including  public, for-profit, and not-for-profit hospitals), interviewed hospital  administrators and emergency department clinicians, and observed  operations in the emergency departments. We also interviewed officials  from local EMS agencies, hospital associations, and other professional  associations and experts knowledgeable about emergency department  crowding.
section_title: Appendix II: Diversion Policies at the Six Locations GAO Visited
paragraphs: While all six locations we visited had local or regional regulations,  policies, or guidelines on ambulance diversion, these policies varied  among and within the locations. For example, the largest emergency  medical services (EMS) provider in the Miami area, the Miami-Dade Fire  Rescue Department EMS Division, stopped allowing hospitals to go on  ambulance diversion as of March 31,1999, though the smaller City of  Miami Fire-Rescue EMS agency did have policies for diversion. As shown  in table 12, the locations we visited illustrate the differences between  diversion policies of different communities and demonstrate how an  episode of diversion in one place differs from an occurrence of diversion  elsewhere.
All six locations had defined types of diversion, including categories such  as overall saturation in the emergency department, diversion for trauma  cases only, diversion because a neurosurgeon was unavailable, diversion  because a computed tomography (CT) scanner was unavailable, or  diversion because of an internal disaster such as a power failure.
Five of the locations had computer-based diversion systems in place at the  time of our visit that allowed EMS dispatchers and hospital officials to  check which hospitals, if any, in the EMS region were on diversion.
All six locations had circumstances under which ambulances would take  patients to the nearest appropriate hospital, regardless of whether the  hospital was on diversion. For example, all six locations had policies to  take patients with unstable or critical conditions to the nearest hospital,  and four had policies that the patient’s request to go to a specific hospital  could override diversion in certain circumstances.
Most of the locations had a specific period after which a hospital would  need to either reconfirm its diversion status or be automatically reopened  to ambulances. However, the policies regarding the time limits varied. For  example, 10 major Boston hospitals were automatically taken off diversion  after 2 hours, while hospitals in Atlanta could go on diversion for up to 8  hours before they would automatically be reopened to all ambulances. In  addition, hospitals in Boston, Phoenix, and Cleveland could be taken off of  diversion status if too many hospitals in their immediate area wanted to go  on diversion. For example, when two-thirds of hospitals in a given sector  in Phoenix are on diversion, all of the hospitals are required to reopen.
section_title: Appendix III: Select Results of GAO Survey of Hospitals Regarding Emergency Department Crowding
paragraphs: This appendix summarizes the results from questions we asked short-term  nonfederal, general medical and surgical hospitals in metropolitan  statistical areas (MSA) in the United States that had emergency  departments in 2000. We sent the questionnaire to 2,041 hospitals that met  these criteria—20 did not have emergency departments in fiscal year 2001  or were closed, for a total of 2,021 hospitals. We obtained responses from  1,489 hospitals, for an overall response rate of about 74 percent. We  weighted responses to adjust for a lower response rate from investor- owned (for-profit) hospitals to provide estimates representative of the  entire universe of 2,021 hospitals in MSAs.
The following tables show select survey information on characteristics of  the survey universe (table 13), emergency department visits and treatment  spaces (tables 14 and 15), specialty on-call coverage (tables 16 and 17),  diversion (tables 18 through 27), boarding (tables 28 through 31), patients  who left before a medical evaluation (table 32), indicators of crowding by  hospital characteristics (tables 33 through 40), hospitals applying for  regulatory approval to increase licensed beds (tables 41 and 42), and payer  sources for emergency department visits (table 43).
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: Other major contributors to this report were Diana Birkett, Jennifer  Cohen, Bruce Greenstein, Katherine Iritani, Susan Lawes, Lisa A. Lusk,  Behn Miller, Dae Park, Tina Schwien, and Stan Stenersen.