Emergency Department Crowding Is More Pronounced in Some Hospitals and Certain Types of Communities

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. 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. Availability of Inpatient Beds for Emergency Patients Cited as a Key Factor Contributing to Crowding, but Other Factors Also Contribute

No single factor stands out as the reason why crowding occurs. 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. department patients to building new, larger emergency departments. 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. 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. To address communitywide factors contributing to  crowding, hospitals may need to work collaboratively with other facilities  in their communities. Comments from External Reviewers

Representatives from the American College of Emergency Physicians and  American Hospital Association and an independent reviewer provided  comments on a draft of this report. This reviewer and the American Hospital Association  provided technical comments that we incorporated as appropriate. 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.
Why GAO Did This Study

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.

What GAO Found

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.