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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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). 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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). 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.

Summary: 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. 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.