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Report to the Chairman, Committee on Finance, U.S. Senate: 

United States Government Accountability Office: 
GAO: 

April 2009: 

Hospital Emergency Departments: 

Crowding Continues to Occur, and Some Patients Wait Longer than 
Recommended Time Frames: 

GAO-09-347: 

GAO Highlights: 

Highlights of GAO-09-347, a report to the Chairman, Committee on 
Finance, U.S. Senate. 

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. 

Table: Average Wait Time to See a Physician and Percentage of Visits in 
Which Wait Time to See a Physician Exceeded Recommended Time Frames by 
Acuity Level, 2006: 

Patient acuity level[A] (recommended time frame): Immediate (less than 
1 minute); 
Average wait time in minutes: 28; 
Percentage of visits in which wait time exceeded recommended time 
frames: 73.9. 

Patient acuity level[A] (recommended time frame): Emergent (1 to 14 
minutes); 
Average wait time in minutes: 37; 
Percentage of visits in which wait time exceeded recommended time 
frames: 50.4. 

Patient acuity level[A] (recommended time frame): Urgent (15 to 60 
minutes); 
Average wait time in minutes: 50; 
Percentage of visits in which wait time exceeded recommended time 
frames: 20.7. 

Patient acuity level[A] (recommended time frame): Semiurgent (greater 
than 1 to 2 hours); 
Average wait time in minutes: 68; 
Percentage of visits in which wait time exceeded recommended time 
frames: 13.3. 

Patient acuity level[A] (recommended time frame): Nonurgent (greater 
than 2 to 24 hours); 
Average wait time in minutes: 76; 
Percentage of visits in which wait time exceeded recommended time 
frames: [B]. 

Source: GAO analysis of data from HHS’s National Center for Health 
Statistics (NCHS). 

Notes: Information on the standard error associated with estimates of 
averages is found in the report. 

[A] Acuity levels describe the recommended time a patient should wait 
to be seen by a physician. NCHS developed acuity levels based on a five-
level emergency severity index recommended by the Emergency Nurses 
Association. 

[B] In 2006, no emergency departments reported visits with wait times 
in excess of 24 hours. 

[End of table] 

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. 

View [hyperlink, http://www.gao.gov/products/GAO-09-347] or key 
components. To view the e-supplement to this report online, click on 
GAO-09-348SP. For more information, contact Marcia Crosse at (202) 512-
7114 or crossem@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

According to Indicators, Emergency Department Crowding Continues: 

Available Information Suggests Lack of Access to Inpatient Beds Is the 
Main Factor Contributing to Crowding, and Other Factors May Also 
Contribute: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Emergency Department Utilization, 2001 through 2006: 

Appendix III: Proposed Measures of Emergency Department Crowding: 

Appendix IV: Emergency Department Wait Times: 

Appendix V: Comments from the Department of Health and Human Services: 

Appendix VI: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Number of Emergency Departments and Emergency Department 
Visits in 2001 through 2006: 

Table 2: Indicators of Emergency Department Crowding: 

Table 3: Percentage of Hospitals That Reported Going on Diversion, and 
Average Hours Hospitals Spent on Diversion in 2003 through 2006: 

Table 4: Average Length of Stay in the Emergency Department, in 
Minutes, and Percentage of Visits in Which Patients Left before a 
Medical Evaluation in 2001 and 2006: 

Table 5: Strategies to Address Indicators of Emergency Department 
Crowding: 

Table 6: Number of Articles Reviewed That Reported Factors Contributing 
to Emergency Department Crowding: 

Table 7: Percentage of Emergency Departments by Hospital Ownership 
Type, Geographic Region, and Type of Area in 2001 through 2006: 

Table 8: Number and Percentage of Emergency Department Visits by Payer 
Source in 2001 through 2006: 

Table 9: Number and Percentage of Emergency Department Visits by 
Hospital Ownership Type, Geographic Region, and Type of Area in 2001 
through 2006: 

Table 10: Number and Percentage of Emergency Department Visits That 
Resulted in Hospital Admissions in 2001 through 2006: 

Table 11: Proposed Measures of Emergency Department Crowding: 

Table 12: Percentage of Emergency Department Visits by Wait Time to See 
a Physician, in 2003 through 2006: 

Table 13: Average Wait Time to See a Physician, in Minutes, by Payer 
Type, Hospital Type, and Geographic Region, in 2003 through 2006: 

Table 14: Average Wait Time to See a Physician, in Minutes, by 
Hospitals' Percentage of Visits in Which Patients Left before a Medical 
Evaluation, in 2003 through 2006: 

Table 15: Percentage of Visits by Emergency Department Length of Stay, 
in 2001 through 2006: 

Table 16: Average Length of Stay in the Emergency Department, in 
Minutes, by Payer Type, Hospital Type, and Geographic Region, in 2001 
through 2006: 

Table 17: Average Length of Stay in the Emergency Department, in 
Minutes, by Hospitals' Percentage of Visits in Which Patients Left 
Before a Medical Evaluation, in 2001 through 2006: 

Figures: 

Figure 1: Percentage of Emergency Departments and Emergency Department 
Visits in Metropolitan and Nonmetropolitan Areas in 2006: 

Figure 2: Percentage of Emergency Department Visits by Acuity Level in 
2006: 

Figure 3: Input-Throughput-Output Model of Emergency Department 
Crowding: 

Figure 4: Average Wait Time to See a Physician, and Percentage of 
Visits in Which Wait Time to See a Physician Exceeded Recommended Time 
Frames by Acuity Level in 2003 and 2006: 

Figure 5: Number and Percentage of Emergency Department Visits by 
Acuity Level in 2001 through 2006: 

Figure 6: Average and Median Wait Time to See a Physician, in Minutes, 
by Acuity Level, in 2003 through 2006: 

Figure 7: Average and Median Length of Stay in the Emergency 
Department, in Minutes, by Acuity Level, in 2001 through 2006: 

Abbreviations: 

ACEP: American College of Emergency Physicians: 

AHRQ: Agency for Healthcare Research and Quality: 

DRG: diagnosis-related group: 

HHS: Department of Health and Human Services: 

IOM: Institute of Medicine: 

NCHS: National Center for Health Statistics: 

NHAMCS: National Hospital Ambulatory Medical Care Survey: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

April 30, 2009: 

The Honorable Max Baucus: 
Chairman: 
Committee on Finance: 
United States Senate: 

Dear Mr. Chairman: 

Open 24 hours a day, 7 days a week, hospital emergency departments are 
a major part of the nation's health care safety net. Of the estimated 
119 million visits to U.S. emergency departments in 2006, over 40 
percent were paid for by federally-supported programs.[Footnote 1] 
These programs--Medicare, Medicaid, and the State Children's Health 
Insurance Program[Footnote 2]--are administered by the Department of 
Health and Human Services (HHS). Emergency department staff report 
being under increasing pressure, and concerns have been raised that 
they face challenges in providing timely and effective emergency 
medical care. For example, considerable attention has been given to 
reports of ambulance diversion--that is, emergency departments 
requesting that ambulances that would normally bring patients to their 
hospitals go instead to other hospitals that are presumably less 
crowded. Concerns have also been raised about the frequency of patients 
remaining in the emergency department--taking up staff and resources-- 
after the decision has been made to admit them to the hospital or 
transfer them to another facility, a practice known as boarding. In 
addition, reports of long wait times in emergency departments have led 
to concerns of potential adverse effects on the quality of care for 
patients, such as prolonged pain and suffering. 

We have reported on the extent of crowding in emergency departments and 
factors contributing to crowding. In 2003, we reported results from our 
survey of more than 2,000 hospitals with emergency departments located 
in metropolitan areas of the country and from our site visits to 
communities where media and other sources had reported problems with 
emergency department crowding.[Footnote 3] Using three indicators of 
crowding--diversion, patients leaving the emergency department before a 
medical evaluation (presumably due to long wait times in the emergency 
department), and boarding--we found that while most emergency 
departments across the country experienced some degree of crowding, 
[Footnote 4] crowding was much more pronounced in some hospitals and 
areas than in others. Generally, hospitals that reported the most 
problems with emergency department crowding were in metropolitan areas 
with populations of 2.5 million or more. We also found that crowding is 
a complex issue and that one key factor contributing to crowding at 
many hospitals was the inability of hospitals to move admitted patients 
out of emergency departments and into inpatient beds. Reasons given for 
why hospitals did not have the capacity to meet demand for inpatient 
beds from emergency department patients included financial pressures 
leading to limited hospital capacity and competition between admissions 
from the emergency department and scheduled admissions, such as for 
elective surgery. Finally, we reported on strategies that were 
implemented to address emergency department crowding in the six 
communities that we visited; however, we found that studies assessing 
the effect of these efforts were limited. 

Since our 2003 report, Congress and others have raised concerns that 
hospital emergency departments are continuing to experience crowded 
conditions that could potentially compromise the nation's ability to 
provide effective emergency medical care. For example, in September 
2003 the Institute of Medicine (IOM) convened a committee to examine, 
among other things, emergency department crowding.[Footnote 5] In 
addition, in June 2007 the House Committee on Oversight and Government 
Reform held a hearing at which experts in hospital emergency care 
testified on the state of the nation's emergency care. Given this 
continued interest, you asked to us to report on information made 
available with respect to emergency department crowding since we issued 
our 2003 report. Specifically, this report examines information made 
available about (1) three indicators of emergency department crowding-
-ambulance diversion, wait times,[Footnote 6] and patient boarding, and 
(2) factors that contribute to emergency department crowding. 

To conduct this work, we reviewed national data, conducted a literature 
review, and interviewed federal and other officials. First, we obtained 
and reviewed national data on emergency department diversion and wait 
times for 2001 through 2006 from the National Center for Health 
Statistics (NCHS)[Footnote 7] and data on hospital admissions--which 
were related to factors of crowding--from the Agency for Healthcare 
Research and Quality (AHRQ).[Footnote 8] We obtained nationally- 
representative data from NCHS and AHRQ beginning with 2001 because 
these data became publicly available in 2003 or later, meeting the 
criterion for inclusion in our analysis. At the time we conducted our 
analysis, the most recent year for which data were available from NCHS 
and AHRQ was 2006. In addition, some data from NCHS were not available 
for all years between 2001 and 2006 because of revisions made by NCHS 
to questions on surveys used to collect information or a low response 
rate to certain questions on these surveys. As part of our review of 
available national data on emergency department diversion and wait 
times, we analyzed wait times in the emergency department using NCHS's 
data on recommended time for a patient to see a physician based on 
patient acuity levels.[Footnote 9] We also reviewed national data on 
emergency department utilization to set up a context for our work. In 
this report, we present NCHS estimates; for those cases in which we 
report an increase or other comparison of these estimates, NCHS tested 
the differences and found them statistically significant.[Footnote 10] 
To assess the reliability of national data from NCHS and AHRQ, we 
discussed the data with agency officials and reviewed the methods they 
used for collecting and reporting these data. We resolved discrepancies 
we found between the data provided to us and data in published reports 
by corresponding with officials from NCHS to obtain sufficient 
explanations for the differences. Based on these steps, we determined 
that these data were sufficiently reliable for our purposes. 

We also conducted a literature review of 197 articles, including 
articles published in peer-reviewed and other periodicals, publications 
from professional and research organizations, and reports issued by 
federal and state agencies. In examining the information made available 
since 2003 about indicators of crowding during our literature review, 
we analyzed articles for what was reported on the effect of crowding on 
patient quality of care and on proposed strategies to address crowding. 
We reviewed 197 articles, publications, and reports (which we call 
articles)[Footnote 11] on emergency department crowding published on or 
between January 1, 2003, and August 31, 2008. These included articles 
reporting on results of surveys conducted by the American College of 
Emergency Physicians (ACEP) and the American Hospital Association that 
provided information on ambulance diversion that was not available from 
NCHS. A complete bibliography for the literature review can be viewed 
at GAO-09-348SP. 

Finally, we interviewed officials from federal agencies and one state 
agency, professional and research organizations, other hospital- 
related organizations, and individual subject-matter experts to obtain 
and review information on indicators of emergency department crowding 
and factors that contribute to crowding. We interviewed federal 
officials from HHS's Centers for Medicare & Medicaid Services and the 
Office of the Assistant Secretary for Preparedness and Response, and 
officials from NCHS and AHRQ who have conducted research on emergency 
department utilization and crowding. We also interviewed officials from 
professional and research organizations, including ACEP, the American 
Hospital Association, the American Medical Association, the Center for 
Studying Health System Change, and the Society for Academic Emergency 
Medicine. Some of the officials from ACEP and the Society for Academic 
Emergency Medicine whom we interviewed have also published research in 
peer-reviewed journals. Additionally, we interviewed hospital-related 
organizations, including those involved in hospital accreditation and 
in developing quality measures for hospital emergency department care, 
and officials from the Massachusetts Department of Public Health. 
Finally, we interviewed three individual subject-matter experts 
knowledgeable about emergency department crowding. Additional 
information about our methodology can be found in appendix I. 

We conducted this performance audit from May 2008 through April 2009 in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. 

Background: 

Thousands of emergency departments operate in the United States, seeing 
millions of patients each year. In our 2003 report on emergency 
department crowding, we reported on the extent of crowding in 
metropolitan areas. Researchers have used three indicators--diversion, 
wait times, and boarding--in examining emergency department crowding. 

Emergency Department Utilization: 

Between 2001 and 2006, according to NCHS estimates, the number of 
emergency departments operating in the United States ranged from about 
4,600 to about 4,900.[Footnote 12] During the same period, the 
estimated number of visits to U.S. emergency departments exceeded 107 
million visits each year, ranging from about 107 million visits in 2001 
to about 119 million visits in 2006. (See table 1.) 

Table 1: Number of Emergency Departments and Emergency Department 
Visits in 2001 through 2006 (In thousands): 

Total number of emergency departments operating: 
2001: 4.6; 
2002: 4.9; 
2003: 4.7; 
2004: 4.7; 
2005: 4.6; 
2006: 4.8. 

Total annual emergency department visit volume: 
2001: 107,490; 
2002: 110,155; 
2003: 113,903; 
2004: 110,216; 
2005: 115,323; 
2006: 119,191. 

Source: GAO analysis of NCHS data. 

Note: All estimates in this table are nationally representative. NCHS 
estimates the number of hospitals with an emergency department in the 
United States that is staffed and operated 24 hours a day. 

[End of table] 

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.[Footnote 13] In 2006, about 
two-thirds of hospitals with emergency departments were located in 
metropolitan areas compared to about one-third in nonmetropolitan 
areas. In the same year, about 101 million (85 percent) of the 
approximately 119 million emergency department visits occurred in 
metropolitan areas compared to about 18 million (15 percent) visits in 
nonmetropolitan areas. (See figure 1.) 

Figure 1: Percentage of Emergency Departments and Emergency Department 
Visits in Metropolitan and Nonmetropolitan Areas in 2006: 

[Refer to PDF for image: two pie-charts] 

Percentage of emergency departments: 
Metropolitan: 66%; 
Nonmetropolitan: 34%. 

Percentage of emergency departments visits: 
Metropolitan: 85%; 
Nonmetropolitan: 15%. 

Source: GAO analysis of NCHS data. 

[End of figure] 

Patients come to the emergency department with illnesses or injuries of 
varying severity, referred to as acuity level. Each acuity level 
corresponds to a recommended time frame for being seen by a physician-
-for example, patients with immediate conditions should be seen within 
1 minute and patients with emergent conditions should be seen within 1 
to 14 minutes. In 2006, urgent patients--patients who are recommended 
to be seen by a physician within 15 to 60 minutes--accounted for the 
highest percentage of visits to the emergency department. (See figure 
2.) 

Figure 2: Percentage of Emergency Department Visits by Acuity Level in 
2006: 

[Refer to PDF for image: pie-chart] 

Percentage of Emergency Department Visits by Acuity Level in 2006: 
Urgent: 37%; 
Semiurgent: 22%; 
No triage/unknown: 13%; 
Nonurgent: 12%; 
Emergent: 11%; 
Immediate: 5%. 

Source: GAO analysis of NCHS data. 

Note: NCHS developed time-based acuity levels based on a five-level 
emergency severity index recommended by the Emergency Nurses 
Association. The acuity levels describe the recommended amount of time 
a patient should wait to be seen by a physician. The recommended time 
frames to see a physician are less than 1 minute for immediate 
patients, between 1 and 14 minutes for emergent patients, between 15 
minutes and 1 hour for urgent patients, greater than 1 hour to 2 hours 
for semiurgent patients, and greater than 2 hours to 24 hours for 
nonurgent patients. 

[End of figure] 

The expected sources of payment[Footnote 14] reported for patients 
receiving emergency department services also vary. For example, from 
2001 through 2006 patients with private insurance accounted for the 
highest number and percentage of visits to the emergency department. 
During the same period, the percentage of uninsured patients[Footnote 
15] seeking care in emergency departments ranged between 15 and 17 
percent of total visits, and the percentage of patients visiting 
emergency departments with Medicare ranged between 14 and 16 percent. 
See appendix II for additional data on expected sources of payment and 
emergency department utilization. 

Key Findings from the 2003 GAO Report on Emergency Department Crowding: 

In 2003, using three indicators that point to situations in which 
crowding is likely occurring--diversion,[Footnote 16] patients leaving 
before a medical evaluation, and boarding--we reported that emergency 
department crowding varied nationwide. We also reported that crowding 
was more pronounced in certain types of communities, and that crowding 
occurred more frequently in hospitals located in metropolitan areas 
with larger populations, higher population growth, and higher levels of 
uninsurance. We reported that crowding was more evident in certain 
types of hospitals, such as in hospitals with higher numbers of staffed 
beds, teaching hospitals, public hospitals, and hospitals designated as 
certified trauma centers. 

In terms of factors that contribute to crowding, we reported that 
crowding is a complex issue and no single factor tends to explain why 
crowding occurs. However, we found that one key factor contributing to 
crowding was the availability of inpatient beds for patients admitted 
to the hospital from the emergency department. Reasons given by 
hospital officials and researchers we interviewed for not always having 
enough inpatient beds to meet demand from emergency patients included 
economic factors that influence hospitals' capability to meet periodic 
spikes in demand and emergency department admissions competing with 
other admissions for inpatient beds. Other additional factors cited by 
researchers and hospital officials as contributing to crowding included 
the lack of availability of physicians and other community services-- 
such as psychiatric services--and the fact that emergency patients are 
older, have more complex conditions, and have more treatment and tests 
provided in the emergency department than in prior years. 

Further, we reported that hospitals and communities had conducted a 
wide range of activities to manage crowding in emergency departments, 
but that problems with crowding persisted in spite of these efforts. 
These activities included efforts to expand capacity and increase 
efficiency in hospitals, and community activities to implement systems 
and rules to manage diversion. These efforts were unable to reverse 
crowding trends at hospital emergency departments, and we found that 
studies assessing the effect of these efforts were limited. 

Indicators of Emergency Department Crowding: 

Researchers use the indicators we reported on in 2003 to point to 
situations in which crowding is likely occurring in emergency 
departments.[Footnote 17] These indicators can point to when crowding 
is likely occurring but they also have limitations. For example, 
patients boarding in the emergency department can indicate that the 
department's capacity to treat additional patients is diminished, but 
it is possible for several patients to be boarding while the emergency 
department has available treatment spaces to see additional patients. 
Table 2 provides the definition of the three indicators of emergency 
department crowding we reviewed in this report--diversion, wait times, 
and boarding--and lists the usefulness and limitations of using these 
indicators to gauge crowding. Regarding wait times, in our 2003 report, 
we used "left before a medical evaluation" as an indicator of crowding 
related to long wait times in an emergency department. Since we issued 
our report in 2003, researchers have used intervals of wait times-- 
including the length of time to see a physician and the total length of 
time a patient is in the emergency department--to indicate when an 
emergency department is crowded. As a result, for this report, we 
examined wait times more broadly, including data on the time for 
patients to see a physician, length of stay in the emergency 
department, and visits in which the patient left before a medical 
evaluation.[Footnote 18] 

Table 2: Indicators of Emergency Department Crowding: 

Indicator: Ambulance diversion; 
Definition: Hospitals request that ambulances bypass their emergency 
departments and transport patients to other medical facilities; 
Usefulness: For emergency departments where local rules permit 
diversion, diversion is an indicator of how often emergency departments 
believe that they cannot safely handle additional ambulance patients; 
Limitations: The number of hours on diversion is a potentially 
imprecise measure of crowding because whether a hospital can go on 
diversion and the circumstances under which it can do so vary from 
location to location, according to both individual hospital policy and 
communitywide guidelines or rules. 

Indicator: Wait times; 
Definition: Intervals of wait time include the amount of time a patient 
waits in the emergency department to see a physician, the percentage of 
visits in which patients left before a medical evaluation, and the 
total length of time a patient spends in the emergency department; 
Usefulness: Long wait times can occur when an emergency department is 
crowded and unable to treat patients waiting to be seen in a reasonable 
amount of time. Excessive wait time is the most common reason patients 
leave the emergency department before being treated; 
Limitations: Since emergency department staff triage patients, those 
with conditions that do not present an immediate emergency generally 
wait the longest. These patients may also be most likely to tire of 
waiting and leave before receiving a medical evaluation. In addition, 
because there are several ways to measure wait times, it can be 
difficult to compare wait times across hospitals or studies. 

Indicator: Patient boarding; 
Definition: A patient remains in the emergency department after the 
decision to admit or transfer the patient has been made, for example 
because an inpatient bed elsewhere in the hospital is not yet 
available; 
Usefulness: Patients boarding in the emergency department take up space 
and resources that could be used to treat other emergency department 
patients. Boarding is an indicator that an emergency department's 
capacity to treat additional patients is diminished; 
Limitations: Boarding does not always indicate that an emergency 
department is crowded since it is possible for an emergency department 
to be boarding patients while also having available treatment spaces. 

Source: GAO. 

[End of table] 

Researchers have developed a conceptual model to analyze the factors 
that contribute to emergency department crowding and develop potential 
solutions.[Footnote 19] This model partitions emergency department 
crowding into three interdependent components: input, throughput, and 
output. Although factors in many different parts of the health care 
system may contribute to emergency department crowding, the model 
focuses on crowding from the perspective of the emergency department. 
(See figure 3.) 

Figure 3: Input-Throughput-Output Model of Emergency Department 
Crowding: 

[Refer to PDF for image: illustration] 

Input (Community): 
Patient demand for emergency department care prior to arrival at the 
emergency department. Demand may be affected by access to health care 
elsewhere in the community. 

Throughput (Emergency Department): 
Patient treatment experiences in the emergency department, including 
triage, diagnostic evaluation, and physician treatment. 

Output (Rest of hospital): 
Patient dispositions following emergency department treatment, 
including discharge from the emergency department, hospital admission, 
and transfer to another facility. 

Source: GAO analysis of published literature, Art Explosion (graphics). 

[End of figure] 

Researchers have used the input-throughput-output model to explain the 
connection between factors that contribute to emergency department 
crowding and indicators of crowding. The three indicators of emergency 
department crowding--diversion, wait times, and boarding--are most 
directly related to the input, throughput, and output components, 
respectively, of the model; but the causes of these indicators can 
relate to other components. For example, a hospital emergency 
department might experience long wait times--an indicator associated 
with the throughput component--because of delays in patients receiving 
laboratory results (related to throughput) or because staff are busy 
caring for patients boarding in the emergency department due to a lack 
of access to inpatient beds (related to output). Similarly, an 
emergency department may divert ambulances (related to input) because 
the emergency department is full due to the inability of hospital staff 
to move admitted patients to hospital inpatient beds (related to 
output). 

According to Indicators, Emergency Department Crowding Continues: 

We found that ambulance diversions continue, wait times have increased, 
and reports of boarding in hospital emergency departments persist. 
Articles we reviewed also reported on the effect of crowding on quality 
of care and on strategies proposed to address crowding. 

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. 
According to NCHS estimates, in 2003, 45 percent of U.S. hospitals 
reported going on diversion, and in 2004 through 2006, between 25 and 
27 percent reported doing so. Of hospitals that reported going on 
diversion, the average number of hours they reported spending on 
diversion varied with an average of 276 hours in 2003 and an average of 
473 hours in 2006.[Footnote 20] (See table 3.) NCHS officials provided 
the percentage of missing diversion data for each year, which ranged 
from 3.75 percent in 2003 to 29.1 percent in 2005.[Footnote 21] NCHS 
officials, however, were unable to provide an explanation for the 
variation of the percentage of hospitals going on diversion in the 
United States and average hours U.S. hospitals reported spending on 
diversion for these years. NCHS reported that hospitals in metropolitan 
areas spent more time on diversion than hospitals in nonmetroplitan 
areas in 2003 through 2004: almost half of hospitals in metropolitan 
areas NCHS surveyed reported spending more than 1 percent of their 
total operating time on diversion in 2003 through 2004,[Footnote 22] 
compared to 1 in 10 hospitals in nonmetropolitan areas.[Footnote 23] 
Some hospitals, however, reported that their state or local laws 
prohibit diversion.[Footnote 24] 

Table 3: Percentage of Hospitals That Reported Going on Diversion, and 
Average Hours Hospitals Spent on Diversion in 2003 through 2006: 

Percentage of hospitals that reported going on diversion[A]: 
2003: 44.5; 
2004: 24.8; 
2005: 26.1; 
2006: 27.3. 

Average hours spent on diversion[B]: 
2003: 276; 
2004: 516; 
2005: 323; 
2006: 473. 

Source: GAO analysis of NCHS data. 

Notes: All estimates in this table are nationally representative. 

[A] Diversion data were missing for 3.75 percent of emergency 
departments in 2003, for 24.1 percent in 2004, for 29.1 percent in 
2005, and for 20.5 percent in 2006. 

[B] Average is the estimated mean. Standard error is a statistic used 
to calculate the range of values that express the possible difference 
between the sample estimate and the actual population value. The 
standard error for average hours spent on diversion was 42 for 2003, 70 
for 2004, 58 for 2005, and 73 for 2006. 

[End of table] 

Other articles that reported on results from surveys also indicated 
that diversion has continued to occur in some hospitals. In 2006 and 
2007, the American Hospital Association conducted surveys of community 
hospital chief executive officers that asked how much time hospitals 
spent on diversion in the previous year.[Footnote 25] The results from 
these surveys show that some hospitals reported going on diversion. 
[Footnote 26] In both American Hospital Association surveys, urban 
hospitals more often reported diversion hours than rural hospitals. For 
example, among hospitals responding to the 2006 American Hospital 
Association survey, about 64 percent of respondents from urban 
hospitals reported going on diversion, compared to about 17 percent of 
respondents from rural hospitals. In addition, articles reporting on 
emergency department crowding in California[Footnote 27] and Maryland 
[Footnote 28] also found that diversion continues to occur and that the 
time hospitals spent on diversion varied.[Footnote 29] 

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 example, the average wait time to see a physician increased 
from 46 minutes in 2003 to 56 minutes in 2006.[Footnote 30] Average 
wait times also increased for patients in some acuity levels.[Footnote 
31] (See figure 4.) For emergent patients,[Footnote 32] the average 
wait time to see a physician increased from 23 minutes to 37 minutes, 
more than twice as long as recommended for their level of acuity. For 
immediate, emergent, urgent, and semiurgent patients, NCHS estimates 
show that some patients were not seen within the recommended time 
frames for their acuity level. 

Figure 4: Average Wait Time to See a Physician, and Percentage of 
Visits in Which Wait Time to See a Physician Exceeded Recommended Time 
Frames by Acuity Level in 2003 and 2006: 

[Refer to PDF for image: table] 

Acuity level[A] (recommended time frame): Immediate[D] (less than 1 
minute); 
Average wait time in minutes[B], 2003: 23; 
Average wait time in minutes[B], 2006: 28; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2003: 37.5; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2006: 73.9. 

Acuity level[A] (recommended time frame): Emergent[D,E] (1 to 14 
minutes); 
Average wait time in minutes[B], 2003: 23; 
Average wait time in minutes[B], 2006: 37; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2003: 37.5; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2006: 50.4. 

Acuity level[A] (recommended time frame): Urgent[E] (15 to 60 minutes); 
Average wait time in minutes[B], 2003: 42; 
Average wait time in minutes[B], 2006: 50; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2003: 17.0; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2006: 20.7. 

Acuity level[A] (recommended time frame): Semiurgent[E] (greater than 1 
hour to 2 hours); 
Average wait time in minutes[B], 2003: 60; 
Average wait time in minutes[B], 2006: 68; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2003: 9.6; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2006: 13.3. 

Acuity level[A] (recommended time frame): Nonurgent (greater than 2 
hours to 24 hours); 
Average wait time in minutes[B], 2003: 69; 
Average wait time in minutes[B], 2006: 76; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2003: [F]; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2006: [F]. 

Acuity level[A] (recommended time frame): No triage[G,H]; 
Average wait time in minutes[B], 2003: 48; 
Average wait time in minutes[B], 2006: 45; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2003: [I]; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2006: [I]. 

Acuity level[A] (recommended time frame): Unknown[H]; 
Average wait time in minutes[B], 2003: 48; 
Average wait time in minutes[B], 2006: 66; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2003: [I]; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2006: [I]. 

Acuity level[A] (recommended time frame): All acuity levels; 
Average wait time in minutes[B], 2003: 46; 
Average wait time in minutes[B], 2006: 56; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2003: [I]; 
Percentage of visits in which wait time exceeded recommended time 
frames[C], 2006: [I]. 

Source: GAO analysis of NCHS data. 

Notes: All estimates in this figure are nationally representative. 

[A] NCHS developed time-based acuity levels based on a five-level 
emergency severity index recommended by the Emergency Nurses 
Association. The acuity levels describe the recommended amount of time 
a patient should wait to be seen by a physician. 

[B] Average is the estimated mean. Standard error is a statistic used 
to calculate the range of values that express the possible difference 
between the sample estimate and the actual population value. The 
standard error for average wait time to see a physician in 2003 ranged 
from 2 to 5 minutes. The standard error for average wait time to see a 
physician in 2006 ranged from 2 to 6 minutes with the exception of a 
standard error of 11 minutes for unknown acuity level. 

[C] The numbers in these columns represent the percentage of visits 
with wait times exceeding the recommended amount of time for their 
acuity level. 

[D] NCHS added an immediate wait time category to the NHAMCS survey 
instrument starting in 2005. For 2003, the emergent category was 
defined as a visit with a recommended wait time of less than 15 
minutes. 

[E] According to NCHS, from 2003 to 2006 the increase in average wait 
time to see a physician for visits by emergent, urgent, and semiurgent 
patients was statistically significant. 

[F] For 2003, wait times in excess of 24 hours were not able to be 
reported on the NHAMCS survey instrument. For 2006, no emergency 
departments in the sample reported visits with wait times in excess of 
24 hours. As a result, the percentages of nonurgent visits with wait 
times exceeding the recommended time frame were not available. 

[G] A visit in which there is no mention of an acuity rating or triage 
level in the medical record, the hospital did not perform triage, or 
the patient was dead on arrival. 

[H] For 2003, the NHAMCS survey instrument grouped no triage and 
unknown acuity level into a single category. 

[I] Visits with no triage reported or an unknown acuity level did not 
have an associated recommended amount of time to see a physician. 
Therefore, percentages of visits with wait times exceeding recommended 
time frames could not be calculated for these categories of visits, or 
all acuity levels combined. 

[End of figure] 

The average wait time to see a physician increased in emergency 
departments in metropolitan areas, and wait times were longer in 
emergency departments in metropolitan areas than in nonmetropolitan 
areas in 2006. In metropolitan-area emergency departments, the average 
wait time to see a physician increased from 51 minutes in 2003 to 60 
minutes in 2006. In nonmetropolitan-area emergency departments, the 
average wait time to see a physician was estimated to be about 26 
minutes in 2003 and 33 minutes in 2006.[Footnote 33] According to NCHS 
data, the average length of stay in the emergency department and the 
percentage of visits in which patients left before a medical evaluation 
also increased. (See table 4.) See appendix IV for additional 
information about wait times in the emergency department. 

Table 4: Average Length of Stay in the Emergency Department, in 
Minutes, and Percentage of Visits in Which Patients Left before a 
Medical Evaluation in 2001 and 2006: 

Average length of stay in the emergency department, in minutes: All 
hospitals; 
2001[A]: 178; 
2006[B]: 199. 

Average length of stay in the emergency department, in minutes: 
Hospitals in metropolitan areas[C]; 
2001[A]: 189; 
2006[B]: 211. 

Average length of stay in the emergency department, in minutes: 
Hospitals in nonmetropolitan areas[C]; 
2001[A]: 131; 
2006[B]: 139. 

Percentage of visits in which patients left before a medical 
evaluation[D]: All hospitals; 
2001[A]: 1.5; 
2006[B]: 2.0. 

Percentage of visits in which patients left before a medical 
evaluation[D]: Hospitals in metropolitan areas[C]; 
2001[A]: 1.7; 
2006[B]: 2.2. 

Percentage of visits in which patients left before a medical 
evaluation[D]: Hospitals in nonmetropolitan areas[C]; 
2001[A]: 0.6; 
2006[B]: 0.9. 

Source: GAO analysis of NCHS data. 

Notes: All estimates in this table are nationally representative. 

[A] Standard error is a statistic used to calculate the range of values 
that express the possible difference between the sample estimate and 
the actual population value. The standard error for the average length 
of stay in the emergency department in 2001 ranged from 4 to 5 minutes. 

[B] The standard error for the average length of stay in the emergency 
department in 2006 ranged from 5 to 7 minutes. 

[C] Metropolitan describes hospitals identified by NCHS as located in a 
metropolitan statistical area and nonmetropolitan describes hospitals 
identified by NCHS as not located in a metropolitan statistical area. 

[D] NCHS defines the percentage of visits in which patients left before 
a medical evaluation as the percentage of visits in which the patient 
left after triage but before receiving any medical care. 

[End of table] 

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. For 
example, in 2006 IOM reported that boarding continues to occur and has 
become a typical practice in hospitals nationwide, with the most 
boarding occurring at large urban hospitals.[Footnote 34] One article 
published in a peer-reviewed journal reported that it is not unusual 
for critically ill patients to board in the emergency department. 
[Footnote 35] In addition, officials we interviewed noted that the 
practice of boarding patients in emergency departments persists. In 
particular, officials from the Center for Studying Health System Change 
noted that boarding still occurs in emergency departments and continues 
to be one of the main indicators of emergency department crowding. 
Officials from ACEP noted that boarding continues to occur in emergency 
departments nationwide and remains a concern for emergency physicians 
and their patients. 

National data on the boarding of patients in the emergency department, 
however, have been limited. In 2006, IOM reported that hospital data 
systems do not adequately monitor or measure patient flow, and 
therefore may be limited in their ability to capture data on boarding. 
For example, few systems distinguish between when a patient is ready to 
move to another location for care and when that move actually takes 
place.[Footnote 36] In addition, from 2001 to 2006, NCHS did not 
collect data on boarding because, according to NCHS officials, data on 
boarding were not easily obtained from patient records. A question 
about emergency department boarding was added to NCHS's NHAMCS 
questionnaire in 2007; however, data from this survey were not 
available at the time we conducted our analysis. Other articles that 
reported on results of surveys conducted by professional associations 
supported officials' statements that boarding has been widespread. For 
example, in an article reporting on a 2005 ACEP survey of emergency 
department directors with a 30 percent response rate, 996 of the 1,328 
respondents reported that they boarded patients for at least 4 hours on 
a daily basis and more than 200 respondents reported that they did so 
for more than 10 patients per day on average.[Footnote 37] 

Articles and Officials Discussed the Effect of Crowding and Strategies 
for Decreasing Diversion, Wait Times, and Boarding: 

Ten of the articles we reviewed and officials from ACEP and the Society 
for Academic Emergency Medicine whom we interviewed raised concerns 
about the adverse effect of diversion, wait times, or boarding on the 
quality of patient care, but quantitative evidence of this effect has 
been limited. Officials from ACEP reported that research has begun to 
analyze the effect of crowding on patient quality of care, and that 
anecdotal reports indicate patients are being harmed. Ten of the 
articles we reviewed discussed the effect of diversion, wait times, or 
boarding on quality of care. One of these articles, the 2006 IOM 
report, noted that ambulance diversion could lead to catastrophic 
delays in treatment for seriously ill or injured patients and that 
boarding may enhance the potential for errors, delays in treatment, and 
diminished quality of care.[Footnote 38] Other articles--some of which 
were published in peer-reviewed journals--also discussed the effect of 
crowding on the quality of patient care, including the following: 

* An examination of the relationship between trauma death rates and 
hospital diversion, which suggested that death rates for trauma 
patients at two hospitals may be correlated with diversion at these 
hospitals.[Footnote 39] 

* A review of 24 hospital emergency departments that suggested when an 
emergency department experienced an increase in the number of patients 
leaving before a medical evaluation, fewer patients with pneumonia at 
the emergency department received antibiotics within the recommended 4 
hours.[Footnote 40] 

* Information from a database of 90 hospitals that showed patients who 
were boarded in the emergency department for more than 6 hours before 
being transferred to the hospital's intensive care unit had an almost 5 
percent higher in-hospital mortality rate than those who were boarded 
for less than 6 hours.[Footnote 41] 

* Five other articles reported potential associations between 
diversion, boarding, and wait times and decreased quality of patient 
care, including articles on the effect of increasing wait times for 
nonurgent patients in the emergency department and delayed treatment 
time for those patients who left before a medical evaluation. 

While these studies support the widely held assertion that emergency 
department crowding adversely affects the quality of patient care, a 
2006 National Health Policy Forum[Footnote 42] report stated that the 
consequences of crowded emergency departments on quality of care have 
not been studied comprehensively and therefore little quantitative 
evidence is available to confirm this assumption.[Footnote 43] 
Officials from the Society for Academic Emergency Medicine reported 
that diversion, wait times, and boarding can contribute to reduced 
quality of care and worse patient outcomes. In addition, officials from 
both ACEP and the Society for Academic Emergency Medicine noted that 
additional studies about the effects of diversion, wait times, and 
boarding on quality of care are needed. 

Articles we reviewed, and officials and an expert we interviewed, 
discussed a number of strategies that have been proposed, and in some 
cases tested, that could decrease emergency department crowding. These 
strategies relate to the three interdependent components--input, 
throughput, and output--of the model of emergency department crowding 
developed by researchers. While several of these strategies have been 
tested, the assessment of their effects has generally been limited to 
one or a few hospitals and we found no research assessing these 
strategies on a state or national level. Table 5 outlines some 
strategies to address emergency department crowding and, to the extent 
they have been tested, the assessment of their effects on the 
indicators of crowding. 

Table 5: Strategies to Address Indicators of Emergency Department 
Crowding: 

Strategies related to emergency department input: 

Strategy: Changing diversion policies for the community; 
Description of strategy: Strategies related to emergency department 
input: A community developed a policy that specified when and under 
what conditions a hospital was allowed to go on diversion. For example, 
hospital officials were required to have a process in place that 
ensured all resources in the hospital were exhausted before going on 
diversion; 
Assessment of the strategy's effect on indicator(s) of crowding: An 
analysis comparing diversion hours before and after implementation of a 
new diversion policy found that this strategy reduced the hours on 
diversion by 74 percent in a community of 17 hospitals.[A] 

Strategy: Physician-directed ambulance destination-control program; 
Description of strategy: Strategies related to emergency department 
input: Emergency medical service providers were asked to call a 
dedicated telephone number that was staffed by attending physicians. A 
destination-control physician determined the optimal patient 
destination by using patient and system variables as well as emergency 
medical service providers' and patients' input; 
Assessment of the strategy's effect on indicator(s) of crowding: An 
analysis comparing the diversion hours with and without this program at 
two hospitals found that this program reduced the hours on diversion by 
41 percent at one hospital and 61 percent at the other hospital.[B] 

Strategy: State policy prohibiting diversion; 
Description of strategy: Strategies related to emergency department 
input: State officials developed a policy that would prohibit hospitals 
from going on diversion unless the hospital is inoperable under certain 
conditions; 
Assessment of the strategy's effect on indicator(s) of crowding: 
Officials from the state of Massachusetts issued a letter stating that 
hospitals would no longer be allowed to go on diversion unless the 
hospital was inoperable; however, this policy was implemented in 
January 2009 and the effect on diversion had not yet been analyzed.[C] 

Strategies related to emergency department throughput: 

Strategy: A fast-track system; 
Description of strategy: Strategies related to emergency department 
input: A system that allowed nonurgent patients to be treated in less 
time because these patients can be seen by a medical provider other 
than a physician; 
Assessment of the strategy's effect on indicator(s) of crowding: An 
analysis comparing wait times before and after implementation of a fast-
track system at one hospital found that this strategy reduced both the 
amount of time patients waited to be seen by a physician and the number 
of patients who left before a medical evaluation by 50 percent.[D] 

Strategy: A point-of-care testing satellite laboratory; 
Description of strategy: Strategies related to emergency department 
input: A testing laboratory was set up in close proximity to the 
emergency department and staffed with a research nurse and laboratory 
technicians. These staff made rounds to the emergency department to 
collect specimens every 15 minutes and reported results directly to 
clinicians in the emergency department by telephone or by fax; 
Assessment of the strategy's effect on indicator(s) of crowding: An 
analysis reviewing effects of implementation of a point-of-care testing 
laboratory in a large university-associated urban hospital found that 
turnaround times for test results were reduced by an average of 87 
percent and length of stay in the emergency department decreased for 
some patients by an average of 41 minutes.[E] 

Strategy: A rapid entry and accelerated care at triage process; 
Description of strategy: Strategies related to emergency department 
input: A hospital computer system was revised to integrate the 
emergency department computer system with the computer system for the 
rest of the hospital, creating a new process when entering data for 
patients at triage. This process allowed staff to eliminate some of the 
administrative work associated with patients entering the emergency 
department; 
Assessment of the strategy's effect on indicator(s) of crowding: An 
analysis comparing wait times before and after initiation of this 
process at one hospital found the process significantly decreased both 
the rate of patients leaving before being seen and average wait times. 
The rate of patients leaving before being seen decreased by 3.3 percent 
and the average wait time decreased by 24 minutes.[F] 

Strategy: Bedside registration; 
Description of strategy: Strategies related to emergency department 
input: During times when emergency department rooms or beds were 
available, patients were transported immediately after triage to a 
patient-care area where they could be simultaneously seen by medical 
staff and registered at the bedside by a registration clerk; 
Assessment of the strategy's effect on indicator(s) of crowding: An 
analysis of treatment time before and after implementation of bedside 
registration at one hospital found a small, significant decrease of 13 
minutes for treatment time after bedside registration was implemented. 
However, this decrease did not last and treatment time even increased a 
year after bedside registration was implemented at this hospital.[G] 

Strategies related to emergency department output: 

Strategy: Increase the capacity of the adult intensive care unit; 
Description of strategy: Strategies related to emergency department 
input: A hospital expanded the number of beds in its adult intensive 
care unit from 47 to 67 beds; 
Assessment of the strategy's effect on indicator(s) of crowding: An 
analysis comparing diversion hours before and after the number of adult 
intensive care unit beds had increased at one hospital found that hours 
on diversion decreased by 66 percent.[H] 

Strategy: Boarding in the inpatient hallways; 
Description of strategy: Strategies related to emergency department 
input: A system for moving nonurgent patients admitted to the hospital 
to inpatient hallways instead of boarding them in emergency department 
hallways; 
Assessment of the strategy's effect on indicator(s) of crowding: Not 
analyzed in published articles[I,J] 

Strategy: A pull system in the hospital; 
Description of strategy: Strategies related to emergency department 
input: Staff on inpatient floors played an active role in placing 
emergency department patients into available beds; 
Assessment of the strategy's effect on indicator(s) of crowding: Not 
analyzed in published articles[J,K] 

Strategy: Streamlining of elective surgery schedules; 
Description of strategy: Strategies related to emergency department 
input: The strategy will streamline elective surgery schedules to make 
elective daily admission volume even, and increase the opportunity for 
emergency department admissions; 
Assessment of the strategy's effect on indicator(s) of crowding: Case 
studies were conducted at several hospitals to determine the influence 
of reducing the variability of elective surgical scheduling. In one 
hospital, waiting times for emergent and urgent surgeries has been 
reduced by about 33 percent despite a 30 percent increase in their 
volumes.[L] 

Source: GAO analysis of articles published between January 1, 2003, and 
August 31, 2008, and interviews. 

[A] P. B. Patel et al., "Ambulance Diversion Reduction: the Sacramento 
Solution," American Journal of Emergency Medicine, vol. 24, no. 2 
(2006). 

[B] M. N. Shah et al., "Description and Evaluation of a Pilot Physician-
directed Emergency Medical Services Diversion Control Program," 
Academic Emergency Medicine, vol. 13, no. 1 (2006). 

[C] The Commonwealth of Massachusetts, Executive Office of Health and 
Human Services, Department of Public Health, Circular Letter: DHCQ 08- 
07-494 (Boston, Mass., July 3, 2008). 

[D] M. Sanchez et al., "Effects of a Fast-Track Area on Emergency 
Department Performance," The Journal of Emergency Medicine, vol. 31, 
no. 1 (2006). 

[E] E. Lee-Lewandrowski et al., "Implementation of a Point-of-Care 
Satellite Laboratory in the Emergency Department of an Academic Medical 
Center Impact on Test Turnaround Time and Patient Emergency Department 
Length of Stay," Archives of Pathology & Laboratory Medicine, vol. 127, 
no. 4 (2003). 

[F] T. C. Chan et al., "Impact of Rapid Entry and Accelerated Care at 
Triage on Reducing Emergency Department Patient Wait Times, Lengths of 
Stay, and Rate of Left Without Being Seen," Annals of Emergency 
Medicine, vol. 46, no. 6 (2005). 

[G] K. M. Takakuwa, F. S. Shofer, and S. B. Abbuhl, "Strategies for 
Dealing with Emergency Department Overcrowding: A One-Year Study on How 
Bedside Registration Affects Patient Throughput Times," The Journal of 
Emergency Medicine, vol. 32, no. 4 (2007). 

[H] K. J. McConnel et al., "Effect of Increased ICU Capacity on 
Emergency Department Length of Stay and Ambulance Diversion," Annals of 
Emergency Medicine, vol. 45, no. 5 (2005). 

[I] C. Garson et al., "Emergency Department Patient Preferences for 
Boarding Locations When Hospitals Are at Full Capacity," Annals of 
Emergency Medicine, vol. 51, no. 1 (2008). 

[J] While researchers have proposed this strategy to alleviate 
crowding, analysis has not been published in articles we reviewed to 
determine if this strategy would decrease boarding. 

[K] M. Wilson and K. Nguyen, "Bursting at the Seams, Improving Patient 
Flow to Help America's Emergency Departments," (Washington, D.C.: 
Urgent Matters, September 2004), [hyperlink, 
http://www.urgentmatters.org/reports/UM_WhitePaper_BurstingAtTheSeams.pd
f] (accessed Sept. 30, 2008). 

[L] Description of strategy and assessment based on conversation with a 
subject-matter expert who oversaw these efforts. Additional information 
is also available on [hyperlink, http://www.bu.edu/mvp] (accessed on 
Apr. 9, 2009). 

[End of table] 

Available Information Suggests Lack of Access to Inpatient Beds Is the 
Main Factor Contributing to Crowding, and Other Factors May Also 
Contribute: 

Available information suggests that a lack of access to inpatient beds 
is the main factor contributing to emergency department crowding. 
Additionally, other factors--a lack of access to primary care, a 
shortage of available on-call specialists, and difficulties 
transferring, admitting, or discharging psychiatric patients--have also 
been reported as contributing to crowding. 

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[Footnote 44] reporting it was the main factor contributing to 
crowding.[Footnote 45] (See table 6.) In addition, two individual 
subject-matter experts we interviewed also reported a lack of access to 
inpatient beds as the main factor that contributes to emergency 
department crowding. When inpatient beds are not available for ill and 
injured patients who require hospital admission, the emergency 
department may board them, and these patients take up extra treatment 
spaces and emergency department resources, leaving fewer resources 
available for other patients. 

Table 6: Number of Articles Reviewed That Reported Factors Contributing 
to Emergency Department Crowding: 

Factor: Lack of access to inpatient beds; 
Number of articles reporting this factor as one of a number of factors 
contributing to crowding: 45. 

Factor: Lack of access to primary care; 
Number of articles reporting this factor as one of a number of factors 
contributing to crowding: 22. 

Factor: Shortage of available on-call specialists; 
Number of articles reporting this factor as one of a number of factors 
contributing to crowding: 7. 

Factor: Difficulty transferring, admitting, or discharging psychiatric 
patients; 
Number of articles reporting this factor as one of a number of factors 
contributing to crowding: 3. 

Factor: Other factors[A]; 
Number of articles reporting this factor as one of a number of factors 
contributing to crowding: 15. 

Factor: Total number of articles reporting factors contributing to 
emergency department crowding; 
Number of articles reporting this factor as one of a number of factors 
contributing to crowding: 77. 

Source: GAO analysis of articles published on or between January 1, 
2003, and August 31, 2008. 

Notes: Numbers do not sum to total because some articles reported more 
than one factor. 

[A] Five other factors--an aging population, increasing acuity of 
patients, staff shortages, hospital processes, and financial factors-- 
were mentioned in 15 articles. During our interviews with officials and 
individual subject-matter experts, however, there was little mentioned 
about these factors and how they contribute to crowding. 

[End of table] 

One of the reasons that emergency departments are unable to move 
admitted patients to inpatient beds may be due to competition between 
emergency department admissions and scheduled hospital admissions--for 
example, for elective surgical procedures--which we also reported on in 
2003. This reason was reported by 9 articles we reviewed and by 
officials from ACEP, the Society for Academic Emergency Medicine, the 
Center for Studying Health System Change, and three individual subject- 
matter experts whom we interviewed. In 2006, IOM reported that 
hospitals might prefer scheduled admissions over admissions from the 
emergency department because emergency department admissions are 
considered to be less profitable.[Footnote 46] One reason that 
admissions from the emergency department are considered to be less 
profitable is because these admissions tend to be for medical 
conditions, such as heart failure and pneumonia, rather than surgical 
procedures, such as joint replacement surgeries and scheduled 
cardiovascular procedures. Available data from AHRQ's 2006 Healthcare 
Cost and Utilization Project[Footnote 47] show all 20 of the most- 
prevalent diagnosis-related groups (DRG)[Footnote 48] associated with 
admissions from the emergency department in 2006 were for medical 
conditions rather than surgical procedures. In contrast, 7 of the 20 
most-prevalent DRGs for nonemergency department admissions in 2006 were 
for surgical conditions. Officials from the Society for Academic 
Emergency Medicine told us that because treating surgical conditions is 
considered more profitable for a hospital than treating emergency 
medical conditions, hospitals had an incentive to reserve beds for 
scheduled surgical admissions rather than to give them to patients 
admitted from the emergency department.[Footnote 49] 

Additional Factors Reported as Contributing to Crowding: 

Available information suggests that other factors also contribute to 
emergency department crowding including a lack of access to primary 
care, a shortage of available on-call specialists, and difficulties 
transferring, admitting, or discharging psychiatric patients. 

Lack of Access to Primary Care: 

Twenty-two articles we reviewed reported a lack of access to primary 
care as a factor contributing to emergency department crowding. For 
example, one of these articles reported that difficulty in receiving 
care from a primary care provider was associated with an increase in 
nonurgent emergency department use.[Footnote 50] Another article 
described a study in New Jersey that indicated that almost one-half of 
all emergency department visits within the state that did not result in 
hospital admission could have been avoided with improved access to 
primary care services.[Footnote 51] Additionally, officials from the 
Center for Studying Health System Change and the Society for Academic 
Emergency Medicine mentioned a lack of access to primary care as a 
factor contributing to emergency department crowding. When patients do 
not have a primary care physician, or cannot obtain an appointment with 
a primary care physician, they may go to the emergency department to 
seek primary care services. In addition, patients who do not have 
access to primary care may defer care until their condition has 
worsened, potentially increasing the emergency department resources 
needed to treat the patient's condition. These situations involve 
patients that could have been treated outside of the emergency 
department and may add to the number of patients seeking care at the 
emergency department. 

Articles we reviewed provided conflicting information on the effect of 
increasing numbers of uninsured patients on emergency department 
crowding. Five of the 22 articles that mentioned a lack of access to 
primary care as a factor also reported that increasing numbers of 
uninsured patients also contributed to emergency department crowding. 
For example, 1 article indicated that a reason for longer wait times at 
30 California hospitals in lower-income areas was that these hospitals 
treat a disproportionate number of uninsured patients who may lack 
access to primary care.[Footnote 52] Two other articles we reviewed, 
however, suggested that increasing numbers of uninsured patients is not 
a factor contributing to crowding. For example, the Center for Studying 
Health System Change reported that contrary to the popular belief that 
uninsured people are the major cause of increased emergency department 
use, insured Americans accounted for most of the 16 percent increase in 
visits between 1996 through 1997 and 2000 through 2001.[Footnote 53] In 
addition, officials from AHRQ noted that a larger proportion of 
patients using the emergency department are insured than uninsured. 

Shortage of Available On-Call Specialists: 

Seven articles and officials from the Center for Studying Health System 
Change, ACEP, the American Hospital Association, and the American 
Medical Association whom we interviewed reported that a shortage of on- 
call specialists available to emergency departments is a factor that 
contributes to emergency department crowding. Hospitals often employ on-
call specialists, meaning specialists such as neurosurgeons or 
orthopedic surgeons who only travel to the hospital or emergency 
department when needed and called. When patients wait for long periods 
in the emergency department for an on-call specialist who is not 
immediately available--for example, busy covering other hospitals or in 
surgery--these patients might not receive timely and appropriate care. 
In addition, these patients may utilize treatment spaces and resources 
that could be used to treat other patients, potentially crowding the 
emergency department. 

In 2006 IOM reported that over the preceding several years, hospitals 
had found it increasingly difficult to secure specialists for their 
emergency department patients.[Footnote 54] Additionally, another 
article reported the results of a 2007 American Hospital Association 
survey of hospital chief executive officers that asked about 
maintaining on-call specialist coverage for the emergency department. 
[Footnote 55] While this survey had a low response rate, it indicates 
that hundreds of emergency departments reported experiencing difficulty 
in maintaining on-call coverage for certain specialists. For example, 
of those chief executive officers that responded to the survey (840 
chief executive officers; 17 percent of those surveyed), 44 and 43 
percent noted difficulty in maintaining emergency department on-call 
coverage for orthopedic surgeons and neurosurgeons, respectively. 
Additionally, officials from the Center for Studying Health System 
Change told us that delays in obtaining specialty services may 
contribute to crowding. None of the articles we reviewed, nor officials 
or individual subject-matter experts we interviewed, quantitatively 
assessed the relationship between the availability of on-call 
specialists and emergency department crowding. 

Difficulties in Transferring, Admitting, or Discharging Psychiatric 
Patients: 

Three articles we reviewed and officials from NCHS, ACEP, and the 
Center for Studying Health System Change whom we interviewed reported 
difficulties transferring, admitting, or discharging psychiatric 
patients from the emergency department as a factor contributing to 
emergency department crowding. One of these articles reported the 
results of a national ACEP survey of emergency physicians that asked 
about psychiatric patients in the emergency department.[Footnote 56] Of 
the physicians responding to the survey (328 physicians; approximately 
23 percent of those surveyed), about 40 percent reported that, on 
average, psychiatric patients waited in the emergency department for an 
inpatient bed longer than 8 hours after the decision to admit them had 
been made, including about 9 percent who reported that psychiatric 
patients waited more than 24 hours. Medical patients in the emergency 
department--those diagnosed with nonpsychiatric conditions--generally 
waited less time for an inpatient bed: 7 percent of responding 
physicians reported that, on average, medical patients waited longer 
than 8 hours after the decision to admit them had been made; slightly 
less than 1 percent reported that the medical patients waited more than 
24 hours. In addition, the survey respondents indicated psychiatric 
patients waiting to be transferred or discharged added to the burden of 
an already crowded emergency department and affected access for all 
patients requiring care. Also, officials from NCHS said that 
psychiatric patients in the emergency department are a national concern 
because they are frequent visitors to the emergency department and they 
may spend more than 24 hours in an emergency department. 

National data from NCHS show that, in 2006, psychiatric patients 
constituted a small percentage of emergency department visits but had a 
longer average length of stay in the emergency department. Almost 3 
percent of emergency department visits in 2006 were by patients 
presenting with a complaint of a psychological or mental disorder and 
these patients had an average length of stay in the emergency 
department that was longer than the average length of stay for all 
other visits (397 minutes, compared to 194 minutes for all other 
visits).[Footnote 57] Emergency department patients with psychiatric 
disorders may need to be isolated from other patients and may require 
resources that are not available in many hospitals. Hospital emergency 
departments often have limited or no specialized psychiatric facilities 
and emergency department staff may experience difficulties transferring 
such patients to other facilities, admitting them to the hospital, or 
discharging them from the emergency department. Additionally, emergency 
department staff may spend a disproportionate amount of time and 
resources caring for psychiatric patients while these patients wait for 
transfer, admission, or discharge. 

Other Possible Factors That Contribute to Crowding: 

Our literature review identified five other factors that may contribute 
to emergency department crowding. For example, in 2006 IOM reported 
these five factors--an aging population, increasing acuity of patients, 
staff shortages, hospital processes, and financial factors--as possible 
factors that might contribute to emergency department crowding, 
[Footnote 58] and these five factors were also mentioned in 14 other 
articles we reviewed. However, during our interviews with officials and 
individual subject-matter experts, there was little mentioned about 
these factors and how they contribute to crowding. 

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 commented that strengths 
of the report include its clarity, focus, and tone. 

In addition, HHS commented on the scope of the report and limitations 
of the indicators used in it. HHS suggested that the information 
provided in the report would be strengthened by inclusion of articles 
published prior to 2003 and articles reporting on studies conducted 
outside of the United States. We focused our literature review on 
articles published since 2003 to review information made available 
since we issued our 2003 report. And while articles reporting on 
studies conducted outside of the United States may include valuable 
information regarding aspects of emergency department crowding as it 
occurs in other countries, we reviewed articles reporting on studies 
conducted in the United States because our focus was on the U.S. health 
care system. HHS also commented that the indicators of crowding that we 
used had limitations. As we noted both in our 2003 report and in this 
report, these indicators have limitations but, in the absence of a 
widely accepted standard measure of crowding, they are used by 
researchers to point to situations in which crowding is likely 
occurring. 

HHS also provided technical comments, which we incorporated as 
appropriate. 

As agreed with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies of this report 
to the Secretary of Health and Human Services and other interested 
parties. The report will be available at no charge on GAO's Web site at 
[hyperlink, http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7114 or crossem@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this report. GAO staff members who made major 
contributions to this report are listed in appendix VI. 

Sincerely yours, 

Signed by: 

Marcia Crosse: 
Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology: 

To examine national data made available since 2003 on emergency 
department diversion and wait times, we obtained and reviewed data 
collected by the National Center for Health Statistics (NCHS) through 
its National Hospital Ambulatory Medical Care Survey (NHAMCS).[Footnote 
59] We analyzed available NCHS data[Footnote 60] for 2001 through 2006 
on diversion[Footnote 61] and wait times[Footnote 62] to determine what 
changes, if any, have occurred over time. We analyzed wait time data by 
patient acuity level[Footnote 63] and hospital characteristics, such as 
hospital ownership,[Footnote 64] metropolitan or nonmetropolitan area 
location,[Footnote 65] and geographic region.[Footnote 66] We analyzed 
wait times in the emergency department using NCHS's data on recommended 
time for a patient to see a physician based on patient acuity levels. 
Further, to determine the average length of stay in the emergency 
department for patients who presented with a psychological or mental 
disorder, we analyzed emergency department length of stay by the type 
of patient complaint at time of the visit. We also analyzed NCHS data 
on emergency department utilization by payer source, including 
Medicare, Medicaid, and the State Children's Health Insurance Program, 
[Footnote 67] self pay, no charge or charity care; and by hospital 
characteristics, such as whether the hospital was located in a 
metropolitan or nonmetroplitan area, to provide context for our work. 
We also reviewed and analyzed data from the Agency for Healthcare 
Research and Quality's (AHRQ) Healthcare Cost and Utilization Project 
[Footnote 68] to determine the diagnosis-related groups (DRG)[Footnote 
69] most commonly associated with hospital admissions from the 
emergency department and most commonly associated with non-emergency 
department admissions--information we determined was related to factors 
that contribute to crowding.[Footnote 70] We obtained NCHS and AHRQ 
data beginning with 2001 because these data became publicly available 
in 2003 or later, meeting the criterion for inclusion in our analysis. 
Some data were not available from NCHS for all years between 2001 and 
2006 because of revisions made by NCHS to questions on surveys used to 
collect information and because of low response rates to certain 
questions on these surveys. At the time we conducted our analysis, the 
most recent year for which data were available from NCHS and AHRQ was 
2006. In this report, we present NCHS estimates; for those cases in 
which we report an increase or other comparison of these estimates, 
NCHS tested the differences and found them statistically significant. 
[Footnote 71] To assess the reliability of national data from NCHS and 
AHRQ, we interviewed agency officials and reviewed the methods they 
used for collecting and reporting these data. We resolved discrepancies 
we found between the data provided to us and data in published reports 
by corresponding with officials from NCHS to obtain sufficient 
explanations for the differences.[Footnote 72] Based on these steps, we 
determined that these data were sufficiently reliable for our purposes. 

To examine information available since 2003 about three indicators of 
emergency department crowding and the factors that contribute to 
crowding, we conducted a literature review. In examining information 
made available since 2003 about indicators and factors of crowding 
during our literature review, we analyzed articles for what was 
reported on the effect of crowding on patient quality of care and 
proposed strategies to address crowding. We conducted a structured 
search of 16 databases that included peer-reviewed journal articles and 
other periodicals to capture articles published on or between January 
1, 2003, and August 31, 2008. We searched these databases for articles 
with key words in their title or abstract related to emergency 
department crowding, or indicators and factors of crowding, such as 
versions of the word "crowding," "emergency department," "diversion," 
"wait time," and "boarding." We also included articles published on or 
between January 1, 2003, and August 31, 2008, that were identified as a 
result of our interviews with federal officials, professional and 
research organizations, and subject-matter experts. We also searched 
related Web sites for additional emergency department crowding 
publications, including articles reporting on surveys conducted by 
professional organizations, such as the American Hospital Association. 
For these articles, we identified the number of respondents and 
response rates, and for those with lower response rates, we noted them 
in our report. From all of these sources, we identified over 300 
articles, publications and reports (which we call articles) published 
from January 1, 2003, through August 31, 2008. Within the more than 300 
articles, we excluded articles that were published outside of the 
United States, reported on subjects or data from outside the United 
States, were only available in an abstract form, had a focus other than 
day-to-day emergency department operations, or were unrelated to 
emergency department crowding. We supplemented the articles that were 
not excluded from our search by reviewing references contained in the 
bibliography of these articles for additional articles published on or 
between January 1, 2003, and August 31, 2008, on emergency department 
crowding that met our inclusion criteria. In total, we included 197 
articles[Footnote 73] in our literature review and analyzed these 
articles to summarize information on emergency department crowding, 
including information on diversion, wait times, and boarding, the 
effect of these indicators of crowding on quality of care, proposed 
strategies to decrease these indicators, and factors that contributed 
to emergency department crowding. To review a complete bibliography of 
these articles, see GAO-09-348SP. 

Additionally, we interviewed officials from federal agencies and one 
state agency, officials from professional, research, and other hospital-
related organizations, and individual subject-matter experts to obtain 
and review information on indicators of emergency department crowding 
and factors that contribute to crowding. During our interviews, we 
asked about the effect of crowding on patient quality of care and 
proposed strategies for addressing crowding. We interviewed federal 
officials from the Department of Health and Human Services' Centers for 
Medicare & Medicaid Services and the Office of the Assistant Secretary 
for Preparedness and Response, and officials from NCHS and AHRQ who 
have conducted research on emergency department utilization and 
crowding. We also interviewed officials from the Massachusetts 
Department of Public Health to discuss the state's planned 
implementation of a new diversion policy in January 2009. We 
interviewed officials from professional organizations, including the 
American College of Emergency Physicians (ACEP), the American Hospital 
Association, the American Medical Association, the Emergency Nurses 
Association, the National Association of EMS Physicians, and the 
Society for Academic Emergency Medicine. Some officials from ACEP and 
the Society for Academic Emergency Medicine have published research in 
peer-reviewed journals. In addition, we interviewed officials from 
research organizations, such as the California Healthcare Foundation, 
the Center for Studying Health System Change,[Footnote 74] the Heritage 
Foundation, and the Robert Wood Johnson Foundation's Urgent Matters. We 
interviewed officials from the Joint Commission (an organization 
involved in hospital accreditation), the Medicare Payment Advisory 
Commission (an organization that studies Medicare payment issues and 
reports to Congress), and the National Quality Forum (an organization 
that develops quality measures for emergency department care). We also 
interviewed three individual subject-matter experts who have conducted 
research on emergency department crowding and strategies to reduce 
crowding. 

We conducted this performance audit from May 2008 through April 2009 in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. 

[End of section] 

Appendix II: Emergency Department Utilization, 2001 through 2006: 

This appendix provides information on nationally-representative 
estimates of emergency departments and emergency department visits in 
the United States by characteristics such as patient acuity level, 
payer source, hospital ownership type, geographic region, and type of 
area (metropolitan or nonmetropolitan) from the National Center for 
Health Statistics' (NCHS) National Hospital Ambulatory Medical Care 
Survey (NHAMCS). Specifically, for 2001 through 2006[Footnote 75] this 
appendix presents the following information: 

* the percentage of emergency departments by hospital ownership type, 
by geographic region, and by type of area (metropolitan or 
nonmetropolitan) (table 7); 

* the number and percentage of emergency department visits by acuity 
level (figure 5) and payer source (table 8); 

* the number and percentage of emergency department visits by hospital 
ownership type, geographic region, and type of area (table 9); and: 

* the number and percentage of emergency department visits that 
resulted in hospital admissions (table 10). 

Table 7: Percentage of Emergency Departments by Hospital Ownership 
Type, Geographic Region, and Type of Area in 2001 through 2006: 

Hospital ownership type: Voluntary, nonprofit; 
2001: 62; 
2002: 65; 
2003: 62; 
2004: 67; 
2005: 68; 
2006: 68. 

Hospital ownership type: Government[A]; 
2001: 27; 
2002: 22; 
2003: 27; 
2004: 25; 
2005: 22; 
2006: 22. 

Hospital ownership type: Proprietary; 
2001: 11; 
2002: 13; 
2003: 12; 
2004: 8; 
2005: 9; 
2006: 10. 

Geographic region[B]: Northeast; 
2001: 15; 
2002: 15; 
2003: 16; 
2004: 15; 
2005: 15; 
2006: 14. 

Geographic region[B]: Midwest; 
2001: 30; 
2002: 29; 
2003: 29; 
2004: 30; 
2005: 31; 
2006: 29. 

Geographic region[B]: South; 
2001: 37; 
2002: 38; 
2003: 39; 
2004: 37; 
2005: 37; 
2006: 39. 

Geographic region[B]: West; 
2001: 18; 
2002: 18; 
2003: 17; 
2004: 18; 
2005: 17; 
2006: 19. 

Type of area: Metropolitan[C]; 
2001: 62; 
2002: 60; 
2003: 58; 
2004: 66; 
2005: 65; 
2006: 66. 

Type of area: Nonmetropolitan[C]; 
2001: 38; 
2002: 40; 
2003: 42; 
2004: 34; 
2005: 35; 
2006: 34. 

Source: GAO analysis of NCHS data. 

Notes: Percentages may not sum to 100 because of rounding. 

[A] NCHS defines a government-owned hospital as a hospital operated by 
a state, county, city, city-county, or hospital district or authority. 

[B] NCHS categorizes geographic regions in the NHAMCS as Northeast, 
Midwest, South, and West as defined by the U.S. Census Bureau. 

[C] Metropolitan describes hospitals identified by NCHS as located in a 
metropolitan statistical area, and nonmetropolitan describes hospitals 
identified by NCHS as not located in a metropolitan statistical area. 

[End of table] 

Figure 5: Number and Percentage of Emergency Department Visits by 
Acuity Level in 2001 through 2006: 
Number in thousands (percentage): 

[Refer to PDF for image: table] 

Acuity level[A] (recommended time frame): Immediate[B] (less than 1 
minute); 
2001: 20,691 (19); 
2002: 24,551 (22); 
2003: 17,297 (15); 
2004: 14,202 (13); 
2005: 6,385 (6); 
2006: 6,084 (5). 

Acuity level[A] (recommended time frame): Emergent[B] (1 to 14 
minutes); 
2001: 20,691 (19); 
2002: 24,551 (22); 
2003: 17,297 (15); 
2004: 14,202 (13); 
2005: 11,313 (10); 
2006: 12,817 (11). 

Acuity level[A] (recommended time frame): Urgent (15 to 60 minutes); 
2001: 34,057 (32); 
2002: 37,639 (34); 
2003: 40,128 (35); 
2004: 41,624 (38); 
2005: 38,433 (33); 
2006: 43,666 (37). 

Acuity level[A] (recommended time frame): Semiurgent (greater than 1 
hour to 2 hours); 
2001: 17,543 (16); 
2002: 20,427 (19); 
2003: 22,830 (20); 
2004: 24,012 (22); 
2005: 23,870 (21); 
2006: 26,173 (22). 

Acuity level[A] (recommended time frame): Nonurgent (greater than 2 
hours to 24 hours); 
2001: 9,790 (9); 
2002: 11,209 (10); 
2003: 14,571 (13); 
2004: 13,774 (13); 
2005: 16,068 (14); 
2006: 14,478 (12). 

Acuity level[A] (recommended time frame): No triage[C,D]; 
2001: 25,409 (24); 
2002: 16,328 (15); 
2003: 19,077 (17); 
2004: 16,605 (15); 
2005: 2,397 (2); 
2006: 1,860 (2). 

Acuity level[A] (recommended time frame): Unknown[D]; 
2001: 25,409 (24); 
2002: 16,328 (15); 
2003: 19,077 (17); 
2004: 16,605 (15); 
2005: 16,857 (15); 
2006: 14,114 (12). 

Notes: Percentages may not sum to 100 because of rounding. 

[A] NCHS developed time-based acuity levels based on a five-level 
severity index recommended by the Emergency Nurses Association. The 
acuity levels describe the recommended amount of time a patient should 
wait to be seen by a physician. 

[B] NCHS added an immediate wait time category to the NHAMCS survey 
starting in 2005. For 2001 through 2004, the emergent category was 
defined as a visit with a recommended wait time of less than 15 
minutes. 

[C] A visit in which there is no mention of an acuity rating or triage 
level in the medical record, the hospital did not perform triage, or 
the patient was dead on arrival. 

[D] For 2001 through 2004, the NHAMCS survey instrument grouped no 
triage and unknown triage level into a single category. 

[End of figure] 

Table 8: Number and Percentage of Emergency Department Visits by Payer 
Source in 2001 through 2006: 
Number in thousands (percentage): 

Payer source[A]: Private insurance; 
2001: 43,213 (40); 
2002: 42,802 (39); 
2003: 41,461 (36); 
2004: 39,344(36); 
2005: 39,565 (34); 
2006: 40,037 (34). 

Payer source[A]: Medicare; 
2001: 15,879 (15); 
2002: 16,964 (15); 
2003: 18,525 (16); 
2004: 16,909 (15); 
2005: 16,043 (14); 
2006: 16,780 (14). 

Payer source[A]: Medicaid/State Children's Health Insurance Program; 
2001: 18,789 (18); 
2002: 21,751 (20); 
2003: 24,415 (21); 
2004: 24,489 (22); 
2005: 28,661 (25); 
2006: 30,351 (26). 

Payer source[A]: Worker's compensation; 
2001: 2,665 (3); 
2002: 2,148 (2); 
2003: 2,130 (2); 
2004: 1,964 (2); 
2005: 1,941 (2); 
2006: 2,045 (2). 

Payer source[A]: Self-pay[B]; 
2001: 15,854 (15); 
2002: 15,935 (14); 
2003: 16,066 (14); 
2004: 17,669 (16); 
2005: 18,581 (16); 
2006: 19,260 (16). 

Payer source[A]: No charge/Charity[B]; 
2001: 1,042 (1); 
2002: 1,155 (1); 
2003: 1,113 (1); 
2004: 885 (1); 
2005: 885 (1); 
2006: 1,756 (1). 

Payer source[A]: Other; 
2001: 2,327 (2); 
2002: 2,551 (2); 
2003: 2,800 (2); 
2004: 3,081 (3); 
2005: 2,184 (2); 
2006: 3,311 (3). 

Payer source[A]: Unknown; 
2001: 6,024 (6); 
2002: 5,266 (5); 
2003: 6,014 (5); 
2004: 4,946 (4); 
2005: 5,996 (5); 
2006: 4,314 (4). 

Payer source[A]: Blank; 
2001: 1,697 (2); 
2002: 1,582 (1); 
2003: 1,377 (1); 
2004: 930 (1); 
2005: 1,466 (1); 
2006: 1,337 (1). 

Source: GAO analysis of NCHS data. 

Notes: Percentages may not sum to 100 because of rounding. 

[A] In 2001 through 2004, the survey asked for primary expected source 
of payment. In 2005 and 2006, multiple sources could be reported. For 
the purposes of comparability, in this table, 2005 and 2006 data were 
recoded to produce a primary expected source of payment based on this 
hierarchy of responses: Medicare, Medicaid, private insurance, worker's 
compensation, self-pay, no charge, other, and unknown. 

[B] NCHS defines no insurance as having only self-pay, no charge, or 
charity as payment sources. 

[End of table] 

Table 9: Number and Percentage of Emergency Department Visits by 
Hospital Ownership Type, Geographic Region, and Type of Area in 2001 
through 2006: 
Number in thousands (percentage): 

Hospital ownership type: Voluntary, nonprofit; 
2001: 78,458 (73); 
2002: 76,869 (70); 
2003: 82,170 (72); 
2004: 82,117 (75); 
2005: 83,288 (72); 
2006: 86,731 (73). 

Hospital ownership type: Government[A]; 
2001: 18,663 (17); 
2002: 20,279 (18); 
2003: 21,116 (19); 
2004: 18,832 (17); 
2005: 19,576 (17); 
2006: 20,882 (18). 

Hospital ownership type: Proprietary; 
2001: 10,370 (10); 
2002: 13,007 (12); 
2003: 10,617 (9); 
2004: 9,267 (8); 
2005: 12,459 (11); 
2006: 11,578 (10). 

Geographic region[B]: Northeast; 
2001: 20,802 (19); 
2002: 18,895 (17); 
2003: 23,814 (21); 
2004: 22,274 (20); 
2005: 22,245 (19); 
2006: 22,669 (19). 

Geographic region[B]: Midwest; 
2001: 26,688 (25); 
2002: 26,006 (24); 
2003: 25,205 (22); 
2004: 26,806 (24); 
2005: 28,771 (25); 
2006: 25,735 (22). 

Geographic region[B]: South; 
2001: 40,512 (38); 
2002: 45,544 (41); 
2003: 44,958 (40); 
2004: 41,150 (37); 
2005: 43,871 (38); 
2006: 50,642 (43). 

Geographic region[B]: West; 
2001: 19,489 (18); 
2002: 19,710 (18); 
2003: 19,926 (18); 
2004: 19,986 (18); 
2005: 20,436 (18); 
2006: 20,145 (17). 

Type of area: Metropolitan[C]; 
2001: 88,605 (82); 
2002: 89,170 (81); 
2003: 92,847 (82); 
2004: 94,826 (86); 
2005: 98,622 (86); 
2006: 100,727 (85). 

Type of area: Nonmetropolitan[C]; 
2001: 18,885 (18); 
2002: 20,985 (19); 
2003: 21,056 (19); 
2004: 15,391 (14); 
2005: 16,700 (15); 
2006: 18,464 (16). 

Source: GAO analysis of NCHS data. 

Notes: Percentages may not sum to 100 because of rounding. 

[A] NCHS defines a government-owned hospital as a hospital operated by 
a state, county, city, city-county, or hospital district or authority. 

[B] NCHS categorizes geographic regions in the NHAMCS as Northeast, 
Midwest, South, and West as defined by the U.S. Census Bureau. 

[C] Metropolitan describes hospitals identified by NCHS as located in a 
metropolitan statistical area, and nonmetropolitan describes hospitals 
identified by NCHS as not located in a metropolitan statistical area. 

[End of table] 

Table 10: Number and Percentage of Emergency Department Visits That 
Resulted in Hospital Admissions in 2001 through 2006 (In thousands): 

Number of emergency department visits resulting in hospital admissions: 
2001: 12,626; 
2002: 13,471; 
2003: 15,809; 
2004: 14,615; 
2005: 13,867; 
2006: 15,210. 

Percentage of all emergency department visits resulting in hospital 
admissions: 
2001: 11.7; 
2002: 12.2; 
2003: 13.9; 
2004: 13.3; 
2005: 12.0; 
2006: 12.8. 

Source: GAO analysis of NCHS data. 

[End of table] 

[End of section] 

Appendix III: Proposed Measures of Emergency Department Crowding: 

Researchers continue to use diversion, wait times (including patients 
who left before a medical evaluation), and boarding as indicators to 
point to situations in which crowding is likely occurring in emergency 
departments; however, as we reported in our 2003 report, there is no 
standard measure of the extent to which emergency departments are 
experiencing crowding. In the absence of a widely-accepted standard 
measure of crowding, researchers have proposed and conducted limited 
testing of potential measures of crowding. During our literature review 
of articles on emergency department crowding published on or between 
January 1, 2003, and August 31, 2008, we identified proposed measures 
of crowding that researchers have tested, either in a single hospital 
setting or for a limited period of time. Table 11 describes these 
proposed measures. While researchers have claimed varying levels of 
success using these measures to gauge crowding, we found no widely 
accepted measure of emergency department crowding, and that none of 
these measures of crowding had been widely implemented by researchers 
and health care practitioners. 

Table 11: Proposed Measures of Emergency Department Crowding: 

Measure: Emergency department occupancy rate; 
Description: The total number of patients in the emergency department 
divided by the total number of licensed emergency department treatment 
bays available per hour; 
Scale: An emergency department occupancy rate above 1.0 indicates that 
there are more patients in the emergency department than treatment 
bays. The higher the emergency department occupancy rate, the more 
crowded the emergency department.[A] 

Measure: Emergency department work index, also known as EDWIN; 
Description: A summary statistic that describes the ratio of patients 
in the emergency department at each triage level compared to the number 
of attending physicians and unoccupied beds in the emergency 
department; 
Scale: Higher EDWIN scores are associated with more crowding in the 
emergency department, greater acuity among emergency department 
patients, or both.[B] 

Measure: Emergency department work score; 
Description: A composite score that measures where emergency 
departments utilize resources. The emergency department work score 
incorporates the number of patients in the waiting room, workload per 
nurse for patients under evaluation in the emergency department, and 
the number of patients boarding in the emergency department; 
Scale: Increases in the emergency department work score indicate an 
increased probability that an emergency department will go on 
diversion.[C] 

Measure: National emergency department overcrowding study, also known 
as NEDOCS; 
Description: A screening tool used to determine the degree of emergency 
department crowding at an academic institution. NEDOCS incorporates the 
number of patients in the emergency department, wait times, staffing in 
the emergency department, and emergency department hours on diversion; 
Scale: The NEDOCS score is measured on a scale between 0 and 200. 
Scores over 100 reflect a progressively more crowded emergency 
department.[D] 

Measure: Real-time emergency analysis of demand indicators, also known 
as READI; 
Description: A measure used to predict emergency department demand. The 
READI analysis evaluates treatment space availability, the acuity of 
emergency department patients, the productivity of physicians, and an 
overall measure of demand. The READI analysis uses a bed ratio, an 
acuity ratio, and a provider ratio to create a demand value score; 
Scale: Demand value scores greater than 7 should alert the staff to 
look at each specific ratio to determine possible contributors to 
demand in excess of emergency department capacity.[E] 

Measure: Emergency department crowding scale; 
Description: The scale is used to provide an objective measure of 
emergency department crowding based on a small set of easily accessible 
factors. These factors include the number of attending emergency 
physicians, number of staffed emergency department beds, number of 
critical-care patients, total number of emergency department patients, 
number of staffed hospital beds, and hospital occupancy rate; 
Scale: An emergency department crowding scale score greater than 65 may 
be predictive of both ambulance diversion and the number of patients 
who leave without being seen by a physician.[F] 

Source: GAO analysis of articles published between January 1, 2003, and 
August 31, 2008. 

[A] M. L. McCarthy, et al., "The Emergency Department Occupancy Rate: A 
Simple Measure of Emergency Department Crowding?" Annals of Emergency 
Medicine, vol. 51, no. 1 (2008). 

[B] S. L. Bernstein, et al., "Development and Validation of a New Index 
to Measure Emergency Department Crowding," Academic Emergency Medicine, 
vol. 10, no. 9 (2003). 

[C] S. Epstein and L. Tian, "Development of an Emergency Department 
Work Score to Predict Ambulance Diversion," Academic Emergency 
Medicine, vol. 13, no. 4 (2006). 

[D] S. Weiss, et al., "Estimating the Degree of Emergency Department 
Overcrowding in Academic Medical Centers: Results of the National ED 
Overcrowding Study (NEDOCS)," Academic Emergency Medicine, vol. 11, no. 
1 (2004). 

[E] T. Reeder, et. al., "The Overcrowded Emergency Department: A 
Comparison of Staff Perceptions," Academic Emergency Medicine, vol. 10, 
no. 10 (2003). 

[F] S. Jones, et al., "An Independent Evaluation of Four Quantitative 
Emergency Department Crowding Scales," Academic Emergency Medicine, 
vol. 13, no. 11 (2006). 

[End of table] 

[End of section] 

Appendix IV: Emergency Department Wait Times: 

This appendix provides information on nationally-representative 
estimates of intervals of emergency department wait times in the United 
States: wait time to see a physician, length of stay in the emergency 
department, and the percentage of visits in which patients left before 
a medical evaluation.[Footnote 76] 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). 

Table 12: Percentage of Emergency Department Visits by Wait Time to See 
a Physician, in 2003 through 2006: 

Wait time to see a physician: Less than 15 minutes; 
2003: 23.4; 
2004: 21.5; 
2005: 22.2; 
2006: 21.9. 

Wait time to see a physician: 15 to 59 minutes; 
2003: 39.2; 
2004: 42.3; 
2005: 41.0; 
2006: 39.9. 

Wait time to see a physician: 1 hour or more, but fewer than 2 hours; 
2003: 13.3; 
2004: 14.3; 
2005: 15.4; 
2006: 14.8. 

Wait time to see a physician: 2 hours or more, but fewer than 3 hours; 
2003: 4.3; 
2004: 4.4; 
2005: 5.2; 
2006: 5.5. 

Wait time to see a physician: 3 hours or more, but fewer than 4 hours; 
2003: 1.6; 
2004: 1.8; 
2005: 2.3; 
2006: 2.2. 

Wait time to see a physician: 4 hours or more, but fewer than 6 hours; 
2003: 1.4; 
2004: 1.2; 
2005: 1.4; 
2006: 1.4. 

Wait time to see a physician: 6 hours or more; 
2003: 0.1; 
2004: 0.1; 
2005: 1.1; 
2006: 0.9. 

Wait time to see a physician: Blank; 
2003: 16.7; 
2004: 14.4; 
2005: 11.4; 
2006: 13.5. 

Source: GAO analysis of NCHS data. 

Note: Percentages may not sum to 100 because of rounding. 

[End of table] 

Figure 6: Average and Median Wait Time to See a Physician, in Minutes, 
by Acuity Level, in 2003 through 2006: 

[Refer to PDF for image: table] 

Acuity level[A] (recommended time frame): Immediate[C] (less than 1 
minute): 
2003, Avg (SE)[B]: 23 (2); 
2003 Median: 12; 
2004, Avg (SE)[B]: 26 (2); 
2004 Median: 13; 
2005, Avg (SE)[B]: 30 (4); 
2005 Median: 10; 
2006, Avg (SE)[B]: 28 (3); 
2006 Median: 11. 

Acuity level[A] (recommended time frame): Emergent[C] (1 to 14 
minutes): 
2003, Avg (SE)[B]: 23 (2); 
2003 Median: 12; 
2004, Avg (SE)[B]: 26 (2); 
2004 Median: 13; 
2005, Avg (SE)[B]: 36 (3); 
2005 Median: 15; 
2006, Avg (SE)[B]: 37 (3); 
2006 Median: 17. 

Acuity level[A] (recommended time frame): Urgent (15 to 60 minutes): 
2003, Avg (SE)[B]: 42 (2); 
2003 Median: 26; 
2004, Avg (SE)[B]: 43 (2); 
2004 Median: 28; 
2005, Avg (SE)[B]: 55 (2); 
2005 Median: 32; 
2006, Avg (SE)[B]: 50 (2); 
2006 Median: 30. 

Acuity level[A] (recommended time frame): Semiurgent (greater than 1 
hour to 2 hours): 
2003, Avg (SE)[B]: 60 (2); 
2003 Median: 42; 
2004, Avg (SE)[B]: 60 (2); 
2004 Median: 41; 
2005, Avg (SE)[B]: 69 (3); 
2005 Median: 45; 
2006, Avg (SE)[B]: 68 (3); 
2006 Median: 45. 

Acuity level[A] (recommended time frame): Nonurgent (greater than 2 
hours to 24 hours): 
2003, Avg (SE)[B]: 69 (5); 
2003 Median: 44; 
2004, Avg (SE)[B]: 65 (3); 
2004 Median: 42; 
2005, Avg (SE)[B]: 66 (3); 
2005 Median: 41; 
2006, Avg (SE)[B]: 76 (6); 
2006 Median: 44. 

Acuity level[A] (recommended time frame): No triage[D,E]: 
2003, Avg (SE)[B]: 48 (5); 
2003 Median: 25; 
2004, Avg (SE)[B]: 49 (4); 
2004 Median: 28; 
2005, Avg (SE)[B]: 31 (7); 
2005 Median: 15; 
2006, Avg (SE)[B]: 45 (6); 
2006 Median: 22. 

Acuity level[A] (recommended time frame): Unknown[E]: 
2003, Avg (SE)[B]: 48 (5); 
2003 Median: 25; 
2004, Avg (SE)[B]: 49 (4); 
2004 Median: 28; 
2005, Avg (SE)[B]: 63 (7); 
2005 Median: 27; 
2006, Avg (SE)[B]: 66 (11); 
2006 Median: 30. 

Acuity level[A] (recommended time frame): All Acuity Levels: 
2003, Avg (SE)[B]: 46 (2); 
2003 Median: 27; 
2004, Avg (SE)[B]: 47 (1); 
2004 Median: 29; 
2005, Avg (SE)[B]: 56 (2); 
2005 Median: 31; 
2006, Avg (SE)[B]: 56 (2); 
2006 Median: 31. 

Source: GAO analysis of NCHS data. 

[A] NCHS developed time-based acuity levels based on a five-level 
severity index recommended by the Emergency Nurses Association. The 
acuity levels describe the recommended amount of time a patient should 
wait to be seen by a physician. 

[B] Avg is the estimated mean and SE is the standard error of the 
estimate. Standard error is a statistic used to calculate the range of 
values that express the possible difference between the sample estimate 
and the actual population value. 

[C] NCHS added an immediate wait time category to the NHAMCS survey 
instrument starting in 2005. For 2003 and 2004, the emergent category 
was defined as any visit with a recommended wait time of less than 15 
minutes. 

[D] No triage indicates a visit in which there is no mention of an 
acuity rating or triage level in the medical record, the hospital did 
not perform triage, or the patient was dead on arrival. 

[E] For 2003 and 2004, the NHAMCS survey instrument grouped no triage 
and unknown triage level into a single category. 

[End of figure] 

Table 13: Average Wait Time to See a Physician, in Minutes, by Payer 
Type, Hospital Type, and Geographic Region, in 2003 through 2006: 

Average wait time to see a physician by payer type[B]: Private 
insurance; 
2003 (SE)[A]: 45 (2); 
2004 (SE)[A]: 46 (1); 
2005 (SE)[A]: 55 (2); 
2006 (SE)[A]: 55 (3). 

Average wait time to see a physician by payer type[B]: Medicare; 2003 
(SE)[A]: 40 (2); 
2004 (SE)[A]: 43 (1); 
2005 (SE)[A]: 52 (3); 
2006 (SE)[A]: 52 (3). 

Average wait time to see a physician by payer type[B]: Medicaid/State 
Children's Health Insurance Program; 
2003 (SE)[A]: 49 (2); 
2004 (SE)[A]: 50 (2); 
2005 (SE)[A]: 59 (2); 
2006 (SE)[A]: 56 (2). 

Average wait time to see a physician by payer type[B]: Worker's 
compensation; 
2003 (SE)[A]: 37 (3); 
2004 (SE)[A]: 46 (2); 
2005 (SE)[A]: 39 (3); 
2006 (SE)[A]: 41 (3). 

Average wait time to see a physician by payer type[B]: Self-pay; 
2003 (SE)[A]: 50 (2); 
2004 (SE)[A]: 49 (2); 
2005 (SE)[A]: 57 (3); 
2006 (SE)[A]: 62 (4). 

Average wait time to see a physician by payer type[B]: No 
charge/charity; 
2003 (SE)[A]: 104 (30); 
2004 (SE)[A]: 72 (8); 
2005 (SE)[A]: 69 (7); 
2006 (SE)[A]: 81 (15). 

Average wait time to see a physician by payer type[B]: Other; 
2003 (SE)[A]: 52 (6); 
2004 (SE)[A]: 48 (5); 
2005 (SE)[A]: 58 (4); 
2006 (SE)[A]: 48 (6). 

Average wait time to see a physician by payer type[B]: Unknown or 
blank; 
2003 (SE)[A]: 48 (3); 
2004 (SE)[A]: 56 (4); 
2005 (SE)[A]: 64 (3); 
2006 (SE)[A]: 57 (5). 

Average wait time to see a physician by hospital type: Voluntary, 
nonprofit; 
2003 (SE)[A]: 46 (2); 
2004 (SE)[A]: 47 (2); 
2005 (SE)[A]: 57 (2); 
2006 (SE)[A]: 55 (2). 

Average wait time to see a physician by hospital type: Government[C]; 
2003 (SE)[A]: 51 (6); 
2004 (SE)[A]: 50 (4); 
2005 (SE)[A]: 51 (4); 
2006 (SE)[A]: 59 (7). 

Average wait time to see a physician by hospital type: Proprietary; 
2003 (SE)[A]: 42 (5); 
2004 (SE)[A]: 45 (3); 
2005 (SE)[A]: 57 (7); 
2006 (SE)[A]: 58 (11). 

Average wait time to see a physician by geographic region[D]: 
Northeast; 
2003 (SE)[A]: 48 (3); 
2004 (SE)[A]: 51 (3); 
2005 (SE)[A]: 57 (4); 
2006 (SE)[A]: 56 (3). 

Average wait time to see a physician by geographic region[D]: Midwest; 
2003 (SE)[A]: 42 (2); 
2004 (SE)[A]: 42 (4); 
2005 (SE)[A]: 49 (3); 
2006 (SE)[A]: 50 (4). 

Average wait time to see a physician by geographic region[D]: South; 
2003 (SE)[A]: 48 (4); 
2004 (SE)[A]: 48 (2); 
2005 (SE)[A]: 58 (3); 
2006 (SE)[A]: 61 (4). 

Average wait time to see a physician by geographic region[D]: West; 
2003 (SE)[A]: 48 (5); 
2004 (SE)[A]: 50 (3); 
2005 (SE)[A]: 63 (6); 
2006 (SE)[A]: 49 (5). 

Source: GAO analysis of NCHS data. 

[A] Average is the estimated mean and SE is the standard error of the 
estimate. Standard error is a statistic used to calculate the range of 
values that express the possible difference between the sample estimate 
and the actual population value. 

[B] In 2003 and 2004, the survey asked for primary expected source of 
payment. In 2005 and 2006, multiple sources could be reported. For the 
purposes of comparability, in this table, 2005 and 2006 data were 
recoded to produce a primary expected source of payment based on this 
hierarchy of responses: Medicare, Medicaid, private insurance, worker's 
compensation, self-pay, no charge, other, and unknown. 

[C] NCHS defines a government-owned hospital as a hospital operated by 
a state, county, city, city-county, or hospital district or authority. 

[D] NCHS categorizes geographic regions in the NHAMCS as Northeast, 
Midwest, South, and West as defined by the U.S. Census Bureau. 

[End of table] 

Table 14: Average Wait Time to See a Physician, in Minutes, by 
Hospitals' Percentage of Visits in Which Patients Left before a Medical 
Evaluation, in 2003 through 2006: 

Percentage of visits in which patients left before a medical 
evaluation[A]: Less than 1 percent; 
2003 Avg (SE)[B]: 30 (2); 
2004 Avg (SE)[B]: 30 (1); 
2005 Avg (SE)[B]: 38 (3); 
2006[C] Avg (SE)[B]: 37 (3). 

Percentage of visits in which patients left before a medical 
evaluation[A]: 1 percent to 2.49 percent; 
2003 Avg (SE)[B]: 37 (3); 
2004 Avg (SE)[B]: 43 (3); 
2005 Avg (SE)[B]: 44 (4); 
2006[C] Avg (SE)[B]: 44 (3). 

Percentage of visits in which patients left before a medical 
evaluation[A]: 2.5 percent to 4.49 percent; 
2003 Avg (SE)[B]: 49 (4); 
2004 Avg (SE)[B]: 60 (4); 
2005 Avg (SE)[B]: 58 (6); 
2006[C] Avg (SE)[B]: 60 (5). 

Percentage of visits in which patients left before a medical 
evaluation[A]: 4.5 percent or more; 
2003 Avg (SE)[B]: 66 (5); 
2004 Avg (SE)[B]: 63 (4); 
2005 Avg (SE)[B]: 80 (7); 
2006[C] Avg (SE)[B]: 84 (8). 

Source: GAO analysis of NCHS data. 

[A] NCHS defines the percentage of visits in which patients left before 
a medical evaluation as the percentage of visits in which the patient 
left after triage but before receiving any medical care. 

[B] Avg is the estimated mean and SE is the standard error of the 
estimate. Standard error is a statistic used to calculate the range of 
values that express the possible difference between the sample estimate 
and the actual population value. 

[C] These 2006 data exclude outlier data from a single hospital because 
a majority of visits to this hospital's emergency department resulted 
in lengths of stay that exceeded 24 hours. 

[End of table] 

Table 15: Percentage of Visits by Emergency Department Length of Stay, 
in 2001 through 2006: 

Emergency department length of stay: Less than 60 minutes; 
2001: 16.6; 
2002: 15.8; 
2003: 14.0; 
2004: 13.9; 
2005: 13.7; 
2006: 12.8. 

Emergency department length of stay: 1 hour or more, but fewer than 2 
hours; 
2001: 25.1; 
2002: 25.5; 
2003: 25.2; 
2004: 25.2; 
2005: 24.8; 
2006: 24.0. 

Emergency department length of stay: 2 hours or more, but fewer than 4 
hours; 
2001: 28.5; 
2002: 30.4; 
2003: 30.9; 
2004: 31.0; 
2005: 31.5; 
2006: 33.0. 

Emergency department length of stay: 4 hours or more, but fewer than 6 
hours; 
2001: 9.1; 
2002: 10.8; 
2003: 11.5; 
2004: 11.7; 
2005: 12.8; 
2006: 13.9. 

Emergency department length of stay: 6 hours or more, but fewer than 10 
hours; 
2001: 4.2; 
2002: 5.2; 
2003: 5.7; 
2004: 6.0; 
2005: 6.9; 
2006: 7.3. 

Emergency department length of stay: 10 hours or more, but fewer than 
14 hours; 
2001: 1.5; 
2002: 1.4; 
2003: 1.4; 
2004: 1.4; 
2005: 1.9; 
2006: 1.7. 

Emergency department length of stay: 14 hours or more, but fewer than 
24 hours; 
2001: 1.5; 
2002: 1.4; 
2003: 1.4; 
2004: 1.3; 
2005: 1.6; 
2006: 1.0. 

Emergency department length of stay: 24 or more hours; 
2001: 0.4; 
2002: 0.8; 
2003: 0.6; 
2004: 0.6; 
2005: 0.2; 
2006: 0.5. 

Emergency department length of stay: Blank; 
2001: 13.4; 
2002: 8.7; 
2003: 9.4; 
2004: 9.0; 
2005: 6.7; 
2006: 5.7. 

Source: GAO analysis of NCHS data. 

Note: Percentages may not sum to 100 because of rounding. 

[End of table] 

Figure 7: Average and Median Length of Stay in the Emergency 
Department, in Minutes, by Acuity Level, in 2001 through 2006: 

[Refer to PDF for image: table] 

Acuity level[A] (recommended time frame): Immediate[D] (less than 1 
minute); 
2001, Avg (SE)[B]: 197 (8); 
2001, Med[C]: 132; 
2002, Avg (SE)[B]: 200 (9); 
2002, Med[C]: 139; 
2003, Avg (SE)[B]: 221 (11); 
2003, Med[C]: 149; 
2004, Avg (SE)[B]: 228 (11); 
2004, Med[C]: 155; 
2005, Avg (SE)[B]: 211 (14); 
2005, Med[C]: 143; 
2006, Avg (SE)[B]: 238 (12); 
2006, Med[C]: 174. 

Acuity level[A] (recommended time frame): Emergent[D] (1 to 14 
minutes); 
2001, Avg (SE)[B]: 197 (8); 
2001, Med[C]: 132; 
2002, Avg (SE)[B]: 200 (9); 
2002, Med[C]: 139; 
2003, Avg (SE)[B]: 221 (11); 
2003, Med[C]: 149; 
2004, Avg (SE)[B]: 228 (11); 
2004, Med[C]: 155; 
2005, Avg (SE)[B]: 225 (9); 
2005, Med[C]: 163; 
2006, Avg (SE)[B]: 224 (10); 
2006, Med[C]: 168. 

Acuity level[A] (recommended time frame): Urgent (15 to 60 minutes); 
2001, Avg (SE)[B]: 185 (5); 
2001, Med[C]: 128; 
2002, Avg (SE)[B]: 191 (7); 
2002, Med[C]: 133; 
2003, Avg (SE)[B]: 201 (7); 
2003, Med[C]: 142; 
2004, Avg (SE)[B]: 198 (6); 
2004, Med[C]: 143; 
2005, Avg (SE)[B]: 208 (6); 
2005, Med[C]: 153; 
2006, Avg (SE)[B]: 204 (6) 
2006, Med[C]: 160. 

Acuity level[A] (recommended time frame): Semiurgent (greater than 1 
hour to 2 hours); 
2001, Avg (SE)[B]: 163 (4); 
2001, Med[C]: 124; 
2002, Avg (SE)[B]: 183 (8); 
2002, Med[C]: 129; 
2003, Avg (SE)[B]: 185 (6); 
2003, Med[C]: 134; 
2004, Avg (SE)[B]: 184 (6); 
2004, Med[C]: 129; 
2005, Avg (SE)[B]: 188 (6); 
2005, Med[C]: 140; 
2006, Avg (SE)[B]: 181 (7); 
2006, Med[C]: 136. 

Acuity level[A] (recommended time frame): Nonurgent (greater than 2 
hours to 24 hours); 
2001, Avg (SE)[B]: 147 (6); 
2001, Med[C]: 108; 
2002, Avg (SE)[B]: 155 (7); 
2002, Med[C]: 112; 
2003, Avg (SE)[B]: 156 (7); 
2003, Med[C]: 114; 
2004, Avg (SE)[B]: 158 (7); 
2004, Med[C]: 115; 
2005, Avg (SE)[B]: 161 (5); 
2005, Med[C]: 115; 
2006, Avg (SE)[B]: 169 (9); 
2006, Med[C]: 123. 

Acuity level[A] (recommended time frame): No triage[E,F]; 
2001, Avg (SE)[B]: 176 (12); 
2001, Med[C]: 115; 
2002, Avg (SE)[B]: 216 (32); 
2002, Med[C]: 134; 
2003, Avg (SE)[B]: 190 (12); 
2003, Med[C]: 131; 
2004, Avg (SE)[B]: 191 (9); 
2004, Med[C]: 133; 
2005, Avg (SE)[B]: 123 (8); 
2005, Med[C]: 92; 
2006, Avg (SE)[B]: 159 (17); 
2006, Med[C]: 101. 

Acuity level[A] (recommended time frame): Unknown[F]; 
2001, Avg (SE)[B]: 176 (12); 
2001, Med[C]: 115; 
2002, Avg (SE)[B]: 216 (32); 
2002, Med[C]: 134; 
2003, Avg (SE)[B]: 190 (12); 
2003, Med[C]: 131; 
2004, Avg (SE)[B]: 191 (9); 
2004, Med[C]: 133; 
2005, Avg (SE)[B]: 197 (9); 
2005, Med[C]: 129; 
2006, Avg (SE)[B]: 220 (28); 
2006, Med[C]: 141. 

Source: GAO analysis of NCHS data. 

[A] NCHS developed time-based acuity levels based on a five-level 
severity index recommended by the Emergency Nurses Association. The 
acuity levels describe the recommended amount of time a patient should 
wait to be seen by a physician. 

[B] Avg is the estimated mean and SE is the standard error of the 
estimate. Standard error is a statistic used to calculate the range of 
values that express the possible difference between the sample estimate 
and the actual population value. 

[C] Med indicates the median measurement. 

[D] NCHS added an immediate wait time category to the NHAMCS survey 
instrument starting in 2005. For 2001 through 2004, the emergent 
category was defined as a visit with a recommended wait time of less 
than 15 minutes. 

[E] A visit in which there is no mention of an acuity rating or triage 
level in the medical record, the hospital did not perform triage, or 
the patient was dead on arrival. 

[F] For 2001 through 2004, the NHAMCS survey instrument grouped no 
triage and unknown triage level into a single category. 

[End of figure] 

Table 16: Average Length of Stay in the Emergency Department, in 
Minutes, by Payer Type, Hospital Type, and Geographic Region, in 2001 
through 2006: 

Average length of stay in the emergency department by payer type[B]: 
Private insurance; 
2001 (SE)[A]: 169 (5); 
2002 (SE)[A]: 182 (6); 
2003 (SE)[A]: 183 (5); 
2004 (SE)[A]: 179 (3); 
2005 (SE)[A]: 186 (4); 
2006 (SE)[A]: 190 (6). 

Average length of stay in the emergency department by payer type[B]: 
Medicare; 
2001 (SE)[A]: 225 (6); 
2002 (SE)[A]: 246 (11); 
2003 (SE)[A]: 244 (10); 
2004 (SE)[A]: 242 (9); 
2005 (SE)[A]: 240 (7); 
2006 (SE)[A]: 242 (7). 

Average length of stay in the emergency department by payer type[B]: 
Medicaid/State Children's Health Insurance Program; 
2001 (SE)[A]: 171 (5); 
2002 (SE)[A]: 172 (6); 
2003 (SE)[A]: 176 (6); 
2004 (SE)[A]: 183 (6); 
2005 (SE)[A]: 188 (7); 
2006 (SE)[A]: 188 (5). 

Average length of stay in the emergency department by payer type[B]: 
Worker's compensation; 
2001 (SE)[A]: 116 (5); 
2002 (SE)[A]: 130 (10); 
2003 (SE)[A]: 132 (8); 
2004 (SE)[A]: 128 (6); 
2005 (SE)[A]: 115 (7); 
2006 (SE)[A]: 131 (6). 

Average length of stay in the emergency department by payer type[B]: 
Self-pay; 
2001 (SE)[A]: 172 (6); 
2002 (SE)[A]: 184 (8); 
2003 (SE)[A]: 187 (7); 
2004 (SE)[A]: 192 (6); 
2005 (SE)[A]: 192 (6); 
2006 (SE)[A]: 197 (7). 

Average length of stay in the emergency department by payer type[B]: No 
charge/charity; 
2001 (SE)[A]: 223 (12); 
2002 (SE)[A]: 274 (19); 
2003 (SE)[A]: 267 (20); 
2004 (SE)[A]: 279 (29); 
2005 (SE)[A]: 257 (16); 
2006 (SE)[A]: 247 (19). 

Average length of stay in the emergency department by payer type[B]: 
Other; 
2001 (SE)[A]: 191 (12); 
2002 (SE)[A]: 230 (33); 
2003 (SE)[A]: 198 (11); 
2004 (SE)[A]: 196 (19); 
2005 (SE)[A]: 194 (11); 
2006 (SE)[A]: 207 (17). 

Average length of stay in the emergency department by payer type[B]: 
Unknown; 
2001 (SE)[A]: 179 (11); 
2002 (SE)[A]: 187 (12); 
2003 (SE)[A]: 201 (11); 
2004 (SE)[A]: 195 (11); 
2005 (SE)[A]: 205 (9); 
2006 (SE)[A]: 212 (12). 

Average length of stay in the emergency department by hospital type: 
Voluntary, nonprofit; 
2001 (SE)[A]: 177 (5); 
2002 (SE)[A]: 193 (7); 
2003 (SE)[A]: 193 (5); 
2004 (SE)[A]: 189 (4); 
2005 (SE)[A]: 198 (4); 
2006 (SE)[A]: 195 (5). 

Average length of stay in the emergency department by hospital type: 
Government[C]; 
2001 (SE)[A]: 183 (10); 
2002 (SE)[A]: 194 (13); 
2003 (SE)[A]: 189 (14); 
2004 (SE)[A]: 216 (16); 
2005 (SE)[A]: 189 (12); 
2006 (SE)[A]: 205 (13). 

Average length of stay in the emergency department by hospital type: 
Proprietary; 
2001 (SE)[A]: 175 (13); 
2002 (SE)[A]: 172 (16); 
2003 (SE)[A]: 195 (17); 
2004 (SE)[A]: 176 (16); 
2005 (SE)[A]: 191 (12); 
2006 (SE)[A]: 218 (33). 

Average length of stay in the emergency department by geographic 
region[D]: Northeast; 
2001 (SE)[A]: 209 (8); 
2002 (SE)[A]: 203 (7); 
2003 (SE)[A]: 213 (8); 
2004 (SE)[A]: 200 (5); 
2005 (SE)[A]: 208 (5); 
2006 (SE)[A]: 203 (5). 

Average length of stay in the emergency department by geographic 
region[D]: Midwest; 
2001 (SE)[A]: 157 (9); 
2002 (SE)[A]: 180 (11); 
2003 (SE)[A]: 174 (6); 
2004 (SE)[A]: 190 (8); 
2005 (SE)[A]: 184 (7); 
2006 (SE)[A]: 185 (11). 

Average length of stay in the emergency department by geographic 
region[D]: South; 
2001 (SE)[A]: 173 (6); 
2002 (SE)[A]: 184 (7); 
2003 (SE)[A]: 191 (9); 
2004 (SE)[A]: 186 (6); 
2005 (SE)[A]: 189 (7); 
2006 (SE)[A]: 206 (10). 

Average length of stay in the emergency department by geographic 
region[D]: West; 
2001 (SE)[A]: 187 (11); 
2002 (SE)[A]: 209 (20); 
2003 (SE)[A]: 201 (13); 
2004 (SE)[A]: 201 (10); 
2005 (SE)[A]: 213 (12); 
2006 (SE)[A]: 196 (8). 

Source: GAO analysis of NCHS data. 

[A] Average is the estimated mean and SE is the standard error of the 
estimate. Standard error is a statistic used to calculate the range of 
values that express the possible difference between the sample estimate 
and the actual population value. 

[B] In 2001 through 2004, the survey asked for primary expected source 
of payment. In 2005 and 2006, multiple sources could be reported. For 
the purposes of comparability, in this table, 2005 and 2006 data were 
recoded to produce a primary expected source of payment based on this 
hierarchy of responses: Medicare, Medicaid, private insurance, worker's 
compensation, self-pay, no charge, other, and unknown. 

[C] NCHS defines a government-owned hospital as a hospital operated by 
a state, county, city, city-county, or hospital district or authority. 

[D] NCHS categorizes geographic regions in the NHAMCS as Northeast, 
Midwest, South, and West as defined by the U.S. Census Bureau. 

[End of table] 

Table 17: Average Length of Stay in the Emergency Department, in 
Minutes, by Hospitals' Percentage of Visits in Which Patients Left 
Before a Medical Evaluation, in 2001 through 2006: 

Percentage of visits in which patients left before a medical 
evaluation[A]: Less than 1 percent; 
2001 (SE)[B]: 137 (7); 
2002 (SE)[B]: 150 (12); 
2003 (SE)[B]: 147 (6); 
2004 (SE)[B]: 152 (6); 
2005 (SE)[B]: 145 (6); 
2006[C] (SE)b: 150 (8). 

Percentage of visits in which patients left before a medical 
evaluation[A]: 1 percent to 2.49 percent; 
2001 (SE)[B]: 157 (6); 
2002 (SE)[B]: 158 (8); 
2003 (SE)[B]: 168 (9); 
2004 (SE)[B]: 154 (7); 
2005 (SE)[B]: 163 (7); 
2006[C] (SE)b: 163 (7). 

Percentage of visits in which patients left before a medical 
evaluation[A]: 2.5 percent to 4.49 percent; 
2001 (SE)[B]: 194 (15); 
2002 (SE)[B]: 192 (15); 
2003 (SE)[B]: 180 (13); 
2004 (SE)[B]: 197 (11); 
2005 (SE)[B]: 187 (13); 
2006[C] (SE)b: 193 (11). 

Percentage of visits in which patients left before a medical 
evaluation[A]: 4.5 percent or more; 
2001 (SE)[B]: 227 (16); 
2002 (SE)[B]: 209 (12); 
2003 (SE)[B]: 233 (16); 
2004 (SE)[B]: 216 (12); 
2005 (SE)[B]: 228 (10); 
2006[C] (SE)b: 249 (16). 

Source: GAO analysis of NCHS data. 

[A] NCHS defines the percentage of visits in which patients left before 
a medical evaluation as the percentage of visits in which the patient 
left after triage but before receiving any medical care. 

[B] Average is the estimated mean and SE is the standard error of the 
estimate. Standard error is a statistic used to calculate the range of 
values that express the possible difference between the sample estimate 
and the actual population value. 

[C] These 2006 data exclude outlier data from a single hospital because 
a majority of visits to this hospital's emergency department had 
lengths of stay that exceeded 24 hours. 

[End of table] 

[End of section] 

Appendix V: Comments from the Department of Health and Human Services: 

Note: Page numbers in the draft report may differ from those in this 
report. 

Department Of Health & Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

April 8, 2009: 

Marcia Crosse: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street N.W. 
Washington, DC 20548: 

Dear Ms. Crosse: 

Enclosed are comments on the U.S. Government Accountability Office's 
(GAO) report entitled: Hospital Emergency Departments: Crowding 
Continues to Occur and Some Patients Wait Longer Than Recommended Time 
Frames (GAO-09-347) and Special Publication-Hospital Emergency 
Department: Bibliography (GAO-09-348SP). 

The Department appreciates the opportunity to review this report before 
its publication. 

Sincerely, 

Signed by: 

Barbara Pisaro Clark: 
Acting Assistant Secretary for Legislation: 

Attachment: 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled: 
Hospital Emergency Departments: Crowding Continues To Occur And Some 
Patients Wait Longer Than Recommended Time Frames (GAO-09-347): 

The Department appreciates the opportunity to review and comment on the 
GAO Draft Report and Special Publication entitled, "Hospital Emergency 
Departments: Crowding Continues to Occur and Some Patients Wait Longer 
Than Recommended Time Frames" (GAO-09-347) and "Hospital Emergency 
Department: Bibliography" (GAO-09-348SP), respectively. 

The GAO report, an update of a 2003 GAO survey of the extent of 
emergency department (ED) crowding, demonstrates that ED waiting times 
are continuing to increase and frequently exceed national standards; 
particularly at the highest acuity levels, where delays make the 
biggest difference. Strengths of the report include its clarity, focus, 
and a dispassionate tone. 

However, designed as an update, it excluded articles and studies 
published before 2003. This method presupposes that readers will be 
familiar with the GAO's earlier survey and the large body of literature 
presented in it. The valid interpretation of this updated information 
would be strengthened by the content and context of the findings and 
literature that was reviewed prior to 2003. Moreover, the exclusion of 
studies conducted outside the US (such as relevant studies conducted in 
Australia, the UK, and Canada) may limit the readers' insight to this 
important topic. 

Further, the GAO study focuses on the ED and three commonly cited 
measures of Crowding. It is worth noting that these are process metrics 
and are limited to patient flow within the Emergency Department. This 
is potentially important in that they do not provide a direct measure 
of broader systematic issues of hospital throughput that effect 
emergency department patient flow such as smoothing elective surgery 
schedules and facilitating inpatient discharges and bed turnover. 
Additionally, information regarding process may not be directly related 
to actual patient outcomes such as treatment success or failure, 
adverse outcomes or direct harms resulting from the lack of system 
capacity. The report does discuss this issue on page 19 under "Impact 
of Crowding" and notes the lack of sufficient quantitative evidence to 
confirm this assumption, however it may worth specifically noting the 
limitations of these three process metrics. 

[End of section] 

Appendix VI: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Marcia Crosse, (202) 512-7114 or crossem@gao.gov: 

Acknowledgments: 

In addition to the contact named above, Kim Yamane, Assistant Director; 
Danielle Bernstein; Susannah Bloch; Ted Burik; Aaron Holling; Carla 
Jackson; Ba Lin; Jeff Mayhew; Jessica Smith; and Jennifer Whitworth 
made key contributions to this report. 

[End of section] 

Footnotes: 

[1] S. R. Pitts, R. W. Niska, J. Xu, and C. W. Burt, "National Hospital 
Ambulatory Medical Care Survey: 2006 Emergency Department Summary," 
National Health Statistics Reports, no. 7 (2008). 

[2] Medicare is the federal health program that covers seniors aged 65 
and older and eligible disabled persons. Medicaid is the joint federal 
and state program that finances health care for certain low-income 
individuals. The State Children's Health Insurance Program finances 
health care for low-income, uninsured children whose family incomes 
exceed the eligibility limits under their state's Medicaid program. 

[3] GAO, Hospital Emergency Departments: Crowded Conditions Vary among 
Hospitals and Communities, [hyperlink, 
http://www.gao.gov/products/GAO-03-460] (Washington, D.C.: Mar. 14, 
2003). 

[4] We reported, for example, that two out of three metropolitan 
hospitals reported going on ambulance diversion--that is, asking 
ambulances to bypass their emergency departments and instead transport 
patients to other facilities. 

[5] The objectives of this committee, the Committee on the Future of 
Emergency Care in the United States Health System, were to (1) examine 
the emergency care system in the United States; (2) explore its 
strengths, limitations, and future challenges; (3) describe a desired 
vision for the system; and (4) recommend strategies for achieving this 
vision. The results of the committee's efforts were described in three 
IOM reports released in 2006: Hospital-Based Emergency Care: At the 
Breaking Point; Emergency Care for Children: Growing Pains; and 
Emergency Medical Services: At the Crossroads. 

[6] In this report, we use the broader indicator wait times to include 
patients leaving before a medical evaluation and intervals of wait 
times, such as the amount of time patients wait to see a physician and 
the total time patients spend in the emergency department. The National 
Center for Health Statistics (NCHS) defines the percentage of visits in 
which patients left before a medical evaluation as the percentage of 
visits in which the patient left after triage but before receiving any 
medical care. 

[7] NCHS is an agency within HHS's Centers for Disease Control and 
Prevention that compiles statistical information to guide actions and 
policies to improve health. NCHS annually collects data on hospital 
emergency department utilization in the United States using a 
nationally representative survey, the National Hospital Ambulatory 
Medical Care Survey (NHAMCS). NCHS uses the NHAMCS to gather, analyze, 
and disseminate information on visits to emergency and outpatient 
departments of nonfederal, short-stay, and general hospitals in the 
United States. NCHS weights sample data from the NHAMCS to produce 
national estimates. 

[8] AHRQ is an HHS agency that conducts and supports health services 
research. AHRQ sponsors the Healthcare Cost and Utilization Project, 
which is a family of health care databases and related software tools 
and products developed through a federal-state-industry partnership. 
Data we reviewed from AHRQ came from the Nationwide Inpatient Sample, 
which is one of a number of databases and software tools AHRQ developed 
as part of the Healthcare Cost and Utilization Project. 

[9] NCHS uses patient acuity levels to measure a patient's severity of 
illness. NCHS developed time-based acuity levels based on a five-level 
emergency severity index recommended by the Emergency Nurses 
Association. The NHAMCS collects data on five levels of acuity: 
immediate, emergent, urgent, semiurgent, and nonurgent. Acuity levels 
are assigned by medical staff after patients arrive in a hospital's 
emergency department. 

[10] In addition, for those cases in which we present averages based on 
NCHS data, we are presenting the estimated mean as well as the standard 
error of the estimate. Standard error is a statistic used to calculate 
the range of values that expresses the possible difference between the 
sample estimate and the actual population value. 

[11] For the literature review, we included articles reporting results 
of quantitative analysis, commentaries, articles reporting on 
literature reviews, or other articles, which includes articles 
published on or between January 1, 2003, and August 31, 2008, that were 
identified as a result of our interviews with officials and individual 
subject-matter experts, and from searches of related Web sites. Other 
articles include articles that were published by professional 
associations with reports of their surveys. 

[12] NCHS estimates the number of hospitals with an emergency 
department that is staffed and operated 24 hours a day. 

[13] For the purpose of this report, we use the term metropolitan area 
to indicate facilities and visits identified by NCHS as occurring in a 
metropolitan statistical area as defined by the Office of Management 
and Budget, and nonmetropolitan area to indicate facilities and visits 
identified by NCHS as not in a metropolitan statistical area. The 
Office of Management and Budget defines a metropolitan statistical area 
as an area containing a core-based statistical area associated with at 
least one urbanized area that has a population of at least 50,000, plus 
adjacent counties having a high degree of social and economic 
integration with the core as measured through commuting ties with 
counties contained in the core. 

[14] Expected sources of payment on the NHAMCS include private 
insurance, Medicaid or State Children's Health Insurance Program, 
Medicare, self-pay, no charge or charity, worker's compensation, other 
sources, and unknown sources. 

[15] NCHS defines uninsured patients as those with expected sources of 
payment categories of only self-pay, no charge, or charity. 

[16] Federal law requires hospitals that participate in Medicare to 
screen all people and treat any with emergency medical conditions 
regardless of ability to pay. In certain circumstances, hospitals can 
place themselves on diversionary status and direct certain en route 
ambulances to other hospitals when they are unable to accept additional 
patients. 

[17] While researchers have been using diversion, wait times (including 
patients leaving before a medical evaluation), and boarding as 
indicators that point to situations in which crowding is likely 
occurring, there is still no standard measure to quantify the extent to 
which emergency departments are experiencing crowded conditions. In the 
absence of a widely-accepted standard measure of crowding, researchers 
have proposed and conducted limited testing of potential measures of 
crowding. None of these measures of crowding, however, have been widely 
implemented by researchers and health care practitioners. See appendix 
III for additional information on these potential measures. 

[18] NCHS defines the percentage of visits in which patients left 
before a medical evaluation as the percentage of visits in which the 
patient left after triage but before receiving any medical care. 

[19] See, B. R. Asplin et al., "A Conceptual Model of Emergency 
Department Crowding," Annals of Emergency Medicine, vol. 42, no. 2 
(2003): 173-180. 

[20] The average hours spent on diversion in 2003 was 276 hours with a 
standard error of 42. The average hours spent on diversion in 2006 was 
473 hours with a standard error of 73. Standard error is a statistic 
used to calculate the range of values that expresses the possible 
difference between the sample estimate and the actual population value. 

[21] Diversion data were missing for 3.75 percent of emergency 
departments in 2003, for 24.1 percent in 2004, for 29.1 percent in 
2005, and for 20.5 percent in 2006. 

[22] For 2005 and 2006 the sample sizes were insufficient to calculate 
the average number of hours that nonmetropolitan hospitals reported 
going on diversion. Therefore, we were not able to compare the number 
of hours metropolitan and nonmetropolitan hospitals reported spending 
on diversion. 

[23] C. W. Burt and L. F. McCaig, "Staffing, Capacity, and Ambulance 
Diversion in Emergency Departments: United States, 2003-04," Advance 
Data From Vital and Health Statistics, no. 376 (2006). 

[24] For 2003 and 2004, 8 percent of all hospitals reported that their 
state or local laws prohibit diversion. According to NCHS, some 
hospitals that reported state laws prohibiting diversion also reported 
diversion hours. NCHS reported that the reasons for this are unknown 
but could include respondent or key error, allowable diversions within 
state laws that prohibit only certain types of diversion, change in 
state law after the diversion reporting period, or other factors. We 
did not attempt to validate the number of state or local laws that may 
govern ambulance diversion. 

[25] American Hospital Association, "The State of America's Hospitals," 
Taking the Pulse, A Chartpack (Washington, D.C., April 2006), 
[hyprlink, http://www.aha.org/aha/research-and-trends/health-and-
hospital-trends/2006.html] (accessed June 26, 2008); and American 
Hospital Association, "The 2007 State of America's Hospitals," Taking 
the Pulse, (Washington, D.C., July 2007), [hyperlink, 
http://www.aha.org/aha/research-and-trends/health-and-hospital-
trends/2007.html] (accessed June 26, 2008). 

[26] In its 2006 survey, the American Hospital Association surveyed 
about 4,900 community hospital chief executive officers and received 
1,011 responses, a response rate of 20 percent. Of those hospitals that 
responded, about 425 hospitals (about 42 percent of respondents) 
reported going on diversion at least once during the year. In its 2007 
survey, the American Hospital Association surveyed about 5,000 
community hospital chief executive officers and received 840 responses, 
a response rate of 17 percent. Of those hospitals that responded to the 
survey, about 302 hospitals (about 36 percent of respondents) reported 
going on diversion at least once during the year. 

[27] The Abaris Group, California Emergency Department Diversion 
Project, Report One (Oakland, Calif.: California HealthCare Foundation, 
March 2007). [hyperlink, 
http://www.caeddiversionproject.com/uploads/CAEDDiversionProjectReportOn
e3-21-07.pdf] (accessed Sept. 4, 2008). 

[28] Maryland Health Care Commission, Use of Maryland Hospital 
Emergency Departments: An Update and Recommended Strategies to Address 
Crowding (Baltimore, Md., January 2007), [hyperlink, 
http://mhcc.maryland.gov/hospital_services/acute/emergencyroom/](accesse
d Sept. 17, 2008). 

[29] In California, the total number of hours that hospitals statewide 
reported being on diversion decreased overall, from almost 300,000 
hours in 2003 to less than 200,000 hours in 2006. The number of hours 
spent on diversion in individual counties, however, varied over these 3 
years, with some counties reporting increases and others reporting 
decreases. In Maryland, the percentage of time hospitals statewide 
reported being on diversion increased from 2003 to 2006. Hospitals 
reported that 9.8 percent and 11.5 percent of their total available 
hours were spent on diversion in 2003 and 2006, respectively. 

[30] NCHS did not collect the average wait time to see a physician in 
2001 and 2002. 

[31] According to NCHS, from 2003 to 2006 the increases in average wait 
times to see a physician for visits overall and by emergent, urgent, 
and semiurgent patients were statistically significant. 

[32] NCHS defines emergent patients as patients who, based on triage, 
are recommended to be seen by a physician within 1 to 14 minutes. 

[33] For 2003 and 2006 estimates of average wait time to see physicians 
at metropolitan hospitals the standard errors are within 2 minutes. For 
2003 and 2006 estimates of average wait time to see a physician at 
nonmetropolitan hospitals the standard errors are within 4 minutes. 

[34] Institute of Medicine, Future of Emergency Care, Hospital-Based 
Emergency Care: At the Breaking Point (Washington, D.C.: The National 
Academies Press, 2006). 

[35] L. Fryman and L. Murray, "Managing Acute Head Trauma in a Crowded 
Emergency Department," Journal of Emergency Nursing, vol. 33, no. 3 
(2007). 

[36] Institute of Medicine, Hospital-Based Emergency Care, 154. 

[37] American College of Emergency Physicians, On-call Specialist 
Coverage in U.S. Emergency Departments (Irving, Tex., 2006). 

[38] Institute of Medicine, Hospital-Based Emergency Care, 4. 

[39] C. E. Begley et al., "Emergency Department Diversion and Trauma 
Mortality: Evidence from Houston, Texas," The Journal of Trauma, 
Injury, Infection, and Critical Care, vol. 57, no. 6 (2004). 

[40] J. M. Pines et al., "The Association between Emergency Department 
Crowding and Hospital Performance on Antibiotic Timing for Pneumonia 
and Percutaneous Intervention for Myocardial Infarction," Academic 
Emergency Medicine, vol. 13 no. 8 (2006). The Joint Commission 
(formerly the Joint Commission on Accreditation of Healthcare 
Organizations) and the Centers for Medicare & Medicaid Services have 
published measures of emergency department quality, including the 
percentage of patients with community-acquired pneumonia that receive 
antibiotics within 4 hours of presenting at an emergency department. 

[41] D. B. Chalfin et al., "Impact of Delayed Transfer of Critically 
Ill Patients from the Emergency Department to the Intensive Care Unit," 
Critical Care Medicine, vol. 35, no. 6 (2007). 

[42] The National Health Policy Forum is a nonpartisan organization 
that provides information on health policy issues and works to foster 
more informed government decision making. It serves primarily senior 
staff in Congress, the executive branch, and congressional support 
agencies. 

[43] J. Taylor, Don't Bring Me Your Tired, Your Poor: The Crowded State 
of America's Emergency Departments (Washington, D.C.: National Health 
Policy Forum, 2006). 

[44] See for example, American College of Emergency Physicians, 
Emergency Department Crowding: High-Impact Solutions (Irving, Tex., 
2008). 

[45] No factor other than a lack of inpatient beds was reported in the 
articles we reviewed as the main factor contributing to crowding. The 
next factor most commonly reported as one of a number of factors 
contributing to crowding was a lack of access to primary care, reported 
in 22 articles. 

[46] Institute of Medicine, Hospital-Based Emergency Care, 137. 

[47] Data we reviewed from AHRQ came from the Nationwide Inpatient 
Sample, which is one of a number of databases and software tools AHRQ 
developed as part of the Healthcare Cost and Utilization Project. 

[48] The Centers for Medicare & Medicaid Services uses DRGs to 
establish payment rates for hospitals that provide medical and surgical 
services to patients with Medicare. 

[49] In addition, available data from AHRQ's Healthcare Cost and 
Utilization Project indicate that the source of payment for admissions 
from the emergency department differs in some cases from the source of 
payment for admissions for elective surgeries. For example, for 2006, 
AHRQ estimates that of hospital admissions from the emergency 
department, the source of payment was private insurance for 25 percent 
of admissions, Medicare for 49 percent of admissions, Medicaid for 15 
percent of admissions, uninsured for 8 percent of admissions, and other 
sources for 4 percent of admissions. In the same year, AHRQ estimates 
that of hospital admissions for elective surgeries, the source of 
payment was private insurance for 46 percent of admissions, Medicare 
for 32 percent of admissions, Medicaid for 15 percent of admissions, 
uninsured for 3 percent of admissions, and other sources for 4 percent 
of admissions. 

[50] D. C. Brousseau et al., "The Effect of Prior Interactions with a 
Primary Care Provider on Nonurgent Pediatric Emergency Department Use," 
Archives of Pediatric & Adolescent Medicine, vol. 158, no. 1 (2004). 

[51] D. DeLia, Potentially Avoidable Use of Hospital Emergency 
Departments in New Jersey (New Brunswick, N.J.: Rutgers Center for 
State Health Policy, 2006). 

[52] S. Lambe et al., "Waiting Times in California's Emergency 
Departments," Annals of Emergency Medicine, vol. 41, no. 1 (2003). 

[53] P. Cunningham and J. May, "Insured Americans Drive Surge in 
Emergency Department Visits," Issue Brief, no. 70 (Washington, D.C.: 
Center for Studying Health System Change, October 2003). 

[54] Institute of Medicine, Hospital-Based Emergency Care, 218. 

[55] American Hospital Association, "The 2007 State of America's 
Hospitals," Taking the Pulse (Washington, D.C., July 2007), [hyperlink, 
http://www.aha.org/aha/research-and-trends/health-and-hospital-
trends/2007.html] (accessed June 26, 2008). 

[56] American College of Emergency Physicians, ACEP Psychiatric and 
Substance Abuse Survey 2008 (Dallas, Tex., 2008). 

[57] The standard error is within 80 minutes for average length of stay 
in the emergency department for patients presenting with a complaint of 
a psychological or mental disorder in 2006. The standard error is 
within 4 minutes for average length of stay in the emergency department 
for all other patients in 2006. 

[58] Institute of Medicine, Hospital-Based Emergency Care, 39, 56, 129, 
137. 

[59] NCHS annually collects national health statistical information on 
hospital emergency department utilization in the United States using a 
nationally representative survey, the NHAMCS. NCHS uses the NHAMCS to 
gather, analyze, and disseminate information on visits to emergency and 
outpatient departments of nonfederal, short-stay, and general hospitals 
in the United States. A complex, multistage sample design is used in 
the NHAMCS, which includes primary sampling units (geographic areas 
such as counties or groups of counties), hospitals within these units, 
clinics within outpatient departments, and patient visits within 
emergency departments and clinics. Sample data are weighted to produce 
national estimates. The scope of the emergency department component of 
the NHAMCS includes emergency departments that are staffed and operated 
24 hours a day. 

[60] The data provided by NCHS were estimates. Each estimate has a 
standard error associated with it. For the purposes of this report, we 
report standard errors for averages. 

[61] NCHS began collecting data on diversion in a supplement to the 
NHAMCS that covered the 2-year period of 2003 through 2004. Beginning 
in 2005, NCHS included a question about diversion on the NHAMCS. Due to 
the low response rates for the NHAMCS questions about diversion in 
2004, 2005, and 2006, we were unable to analyze diversion by 
characteristics such as hospital type or geographic region. For 2005 
and 2006 the sample sizes were insufficient to calculate the number of 
hours that nonmetropolitan hospitals reported being on diversion. 
Therefore, we were not able to compare the number of hours metropolitan 
and nonmetropolitan hospitals reported spending on diversion for those 
years. 

[62] NCHS did not collect data on wait times to see a physician in 2001 
or 2002. 

[63] To measure severity of illness, NCHS developed time-based acuity 
levels based on a five-level severity index recommended by the 
Emergency Nurses Association. The acuity levels describe the 
recommended amount of time a patient should wait to be seen by a 
physician. In the 2006 NHAMCS, NCHS collected data on five levels of 
acuity: immediate, emergent, urgent, semiurgent, and nonurgent. 

[64] NCHS uses voluntary nonprofit, government, and proprietary to 
distinguish hospital ownership. NCHS defines a government-owned 
hospital as a hospital operated by a state, county, city, city-county, 
or hospital district or authority. 

[65] For the purpose of this report, we use the term metropolitan area 
to indicate facilities and visits identified by NCHS as occurring in a 
metropolitan statistical area as defined by the Office of Management 
and Budget, and nonmetropolitan area to indicate facilities and visits 
identified by NCHS as not in a metropolitan statistical area. The 
Office of Management and Budget defines a metropolitan statistical area 
as an area containing a core-based statistical area associated with at 
least one urbanized area that has a population of at least 50,000, plus 
adjacent counties having a high degree of social and economic 
integration with the core as measured through commuting ties with 
counties contained in the core. 

[66] NCHS categorizes geographic regions in the NHAMCS as Northeast, 
Midwest, South, and West as defined by the U.S. Census Bureau. 

[67] Medicare is the federal health program that covers seniors aged 65 
and older and eligible disabled persons. Medicaid is the joint federal 
and state program that finances health care for certain low-income 
individuals. The State Children's Health Insurance Program finances 
health care for low-income, uninsured children whose family incomes 
exceed the eligibility limits under their state's Medicaid program. 

[68] AHRQ sponsors the Healthcare Cost and Utilization Project, which 
is a family of health care databases and related software tools and 
products developed through a federal-state-industry partnership. The 
Healthcare Cost and Utilization Project databases bring together the 
data-collection efforts of state data organizations, hospital 
associations, private data organizations, and the federal government to 
create a national information resource of patient-level health care 
data. Data we reviewed from AHRQ came from the Nationwide Inpatient 
Sample, which is one of a number of databases and software tools AHRQ 
developed as part of the Healthcare Cost and Utilization Project. 

[69] The Centers for Medicare & Medicaid Services uses DRGs to 
establish payment rates for hospitals that provide medical and surgical 
services to Medicare beneficiaries. 

[70] We also analyzed data from AHRQ's Healthcare Cost and Utilization 
Project on the source of payment for hospital admissions from the 
emergency department and admissions not from the emergency department 
in 2006. 

[71] In addition, for those cases in which we present averages based on 
NCHS data, we are presenting the estimated mean and as well as the 
standard error of the estimate. Standard error is a statistic used to 
calculate the range of values that expresses the possible difference 
between the sample estimate and the actual population value. 

[72] For example, we compared data on the estimated number of emergency 
departments operating in the United States in 2006 from NCHS with the 
number of emergency departments operating in the United States in 2006 
from the American Hospital Association and found differences. We 
discussed the discrepancy with NCHS officials and, because we chose in 
this report to use other NCHS estimates, we used NCHS's estimates of 
the number of emergency departments throughout the report. 

[73] For the literature review, we included articles reporting results 
of quantitative analysis, commentaries, articles reporting on 
literature reviews, or other articles, including those identified as a 
result of our interviews with officials and individual subject-matter 
experts, and from searches of related Web sites. In total, we reviewed 
80 articles reporting on quantitative analysis, 64 commentaries, 8 
articles reporting on literature reviews, and 45 other articles. 

[74] Officials at the Center for Studying Health System Change are 
researchers who interviewed providers from across the country. 

[75] We obtained NCHS data beginning with 2001 because these data 
became publicly available in 2003 or later, meeting the criterion for 
inclusion in our analysis. At the time we conducted our analysis, the 
most recent year for which data were available from NCHS on emergency 
department utilization was 2006. 

[76] The National Center for Health Statistics (NCHS) defines the 
percentage of patients who left before a medical evaluation as the 
percentage of visits in which the patient left after triage but before 
receiving any medical care. 

[End of section] 

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