Most hospitals with emergency departments are located in metropolitan  areas, and the majority of emergency department visits occurred in  metropolitan areas of the United States. Hospitals Continue to Divert Ambulances

National data show that the diversion of ambulances continues to occur,  but that the percentage of hospitals that go on diversion and the average  number of hours hospitals spend on diversion varied by year. Wait Times Have Increased and in Some Cases Exceeded Recommended Time Frames

National data from NCHS indicate that wait times in the emergency  department have increased and in some cases exceeded recommended  time frames. For  emergent patients, the average wait time to see a physician increased  from 23 minutes to 37 minutes, more than twice as long as recommended  for their level of acuity. Boarding Continues to Be Reported, but National Data on Boarding Have Been Limited

More than 25 percent of the 197 articles we reviewed discuss the practice  of boarding patients in emergency departments, and officials we  interviewed noted that the practice of boarding continues. Additionally,  other factors—a lack of access to primary care, a shortage of available on- call specialists, and difficulties transferring, admitting, or discharging  psychiatric patients—have also been reported as contributing to crowding. Articles and Subject- Matter Experts Have Reported a Lack of Access to Inpatient Beds as the Main Factor Contributing to Crowding

Of the 77 articles we reviewed that discussed factors contributing to  crowding, 45 articles reported a lack of access to inpatient beds as a factor  contributing to emergency department crowding, with 13 of these articles  reporting it was the main factor contributing to crowding. One of the reasons that emergency departments are unable to move  admitted patients to inpatient beds may be due to competition between  emergency department admissions and scheduled hospital admissions— for example, for elective surgical procedures—which we also reported on  in 2003. In 2006, IOM reported that hospitals  might prefer scheduled admissions over admissions from the emergency  department because emergency department admissions are considered to  be less profitable. Agency Comments and Our Evaluation

HHS provided comments on a draft of this report, which are included in  appendix V. In its comments, HHS noted that the report demonstrates that  emergency department wait times continue to increase and frequently  exceed national standards. HHS also provided technical comments, which we incorporated as  appropriate. To examine information available since 2003 about three indicators of  emergency department crowding and the factors that contribute to  crowding, we conducted a literature review. In examining information  made available since 2003 about indicators and factors of crowding during  our literature review, we analyzed articles for what was reported on the  effect of crowding on patient quality of care and proposed strategies to  address crowding. We  searched these databases for articles with key words in their title or  abstract related to emergency department crowding, or indicators and  factors of crowding, such as versions of the word “crowding,” “emergency  department,” “diversion,” “wait time,” and “boarding.” We also included  articles published on or between January 1, 2003, and August 31, 2008, that  were identified as a result of our interviews with federal officials,  professional and research organizations, and subject-matter experts. Specifically, this appendix presents the following information from the  National Center for Health Statistics’ (NCHS) National Hospital  Ambulatory Medical Care Survey (NHAMCS):  for 2003 through 2006 (the only years for which data were available from  NCHS), the percentage of emergency department visits by wait time to see  a physician (table 12), average and median wait times to see a physician by  patient acuity level (figure 6), average wait times to see a physician by  payer type, hospital type, and geographic region (table 13), and average  wait times by the hospitals’ percentage of visits in which patients left  before a medical evaluation (table 14); and for 2001 through 2006, the percentage of visits by emergency department  length of stay (table 15), the average and median length of stay by patient  acuity level (figure 7), the average length of stay in the emergency  department by payer type, hospital type, and geographic region (table 16);  and average length of stay by the hospitals’ percentage of visits in which  patients left before a medical evaluation (table 17).
Why GAO Did This Study

Hospital emergency departments are a major part of the nation's health care safety net. Of the estimated 119 million visits to U.S. emergency departments in 2006, over 40 percent were paid for by federally-supported programs. These programs--Medicare, Medicaid, and the State Children's Health Insurance Program--are administered by the Department of Health and Human Services (HHS). There have been reports of crowded conditions in emergency departments, often associated with adverse effects on patient quality of care. In 2003, GAO reported that most emergency departments in metropolitan areas experienced some degree of crowding (Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities, GAO-03-460). For example, two out of every three metropolitan hospitals reported going on ambulance diversion--asking ambulances to bypass their emergency departments and instead transport patients to other facilities. GAO was asked to examine information made available since 2003 on emergency department crowding. GAO examined three indicators of emergency department crowding--ambulance diversion, wait times, and patient boarding--and factors that contribute to crowding. To conduct this work, GAO reviewed national data; conducted a literature review of 197 articles; and interviewed officials from HHS and professional and research organizations, and individual subject-matter experts.

What GAO Found

Emergency department crowding continues to occur in hospital emergency departments according to national data, articles we reviewed, and officials we interviewed. National data show that hospitals continue to divert ambulances, with about one-fourth of hospitals reporting going on diversion at least once in 2006. National data also indicate that wait times in the emergency department increased, and in some cases exceeded recommended time frames. For example, the average wait time to see a physician for emergent patients--those patients who should be seen in 1 to 14 minutes--was 37 minutes in 2006, more than twice as long as recommended for their level of urgency. Boarding of patients in the emergency department who are awaiting transfer to an inpatient bed or another facility continues to be reported as a problem in articles we reviewed and by officials we interviewed, but national data on the extent to which this occurs are limited. Moreover, some of the articles we reviewed discussed strategies to address crowding, but these strategies have not been assessed on a state or national level. Articles we reviewed and individual subject-matter experts we interviewed reported that a lack of access to inpatient beds continues to be the main factor contributing to emergency department crowding, although additional factors may contribute. One reason for a lack of access to inpatient beds is competition between hospital admissions from the emergency department and scheduled admissions--for example, for elective surgeries, which may be more profitable for the hospital. Additional factors may contribute to emergency department crowding, including patients' lack of access to primary care services or a shortage of available on-call specialists. In commenting on a draft of this report, HHS noted that the report demonstrates that emergency department wait times are continuing to increase and frequently exceed national standards. HHS also provided technical comments, which we incorporated as appropriate.