oversight

Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities

Published by the Government Accountability Office on 2003-03-14.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             United States General Accounting Office

GAO          Report to the Ranking Minority
             Member, Committee on Finance, U.S.
             Senate


March 2003
             HOSPITAL
             EMERGENCY
             DEPARTMENTS
             Crowded Conditions
             Vary among Hospitals
             and Communities




GAO-03-460
                                               March 2003


                                               HOSPITAL EMERGENCY DEPARTMENTS

                                               Crowded Conditions Vary among
Highlights of GAO-03-460, a report to the      Hospitals and Communities
Ranking Minority Member, Committee on
Finance, U.S. Senate




Hospital emergency departments                 While many emergency departments across the country reported some
are a major part of the nation’s               degree of crowding, the problem is more pronounced in certain hospitals
health care safety net. Emergency              and communities. For example, while 2 of every 3 hospitals reported asking
departments report being under                 ambulances to be diverted to other hospitals at some point in fiscal year
increasing pressure, with the                  2001, a smaller portion—about 1 of every 10—reported being on diversion
number of visits nationwide
increasing from an estimated 95
                                               status for more than 20 percent of the year. Hospitals in areas with larger
million in 1997 to an estimated 108            populations, areas with high population growth in recent years, and areas
million in 2000. GAO was asked to              with higher-than-average percentages of people without health insurance
provide information on emergency               reported higher levels of crowding.
department crowding, including the
extent hospitals located in                    While no single factor stands out as the reason why crowding occurs, GAO
metropolitan areas are                         found the factor most commonly associated with crowding was the inability
experiencing crowding, the factors             to transfer emergency patients to inpatient beds once a decision had been
contributing to crowding, and the              made to admit them as hospital patients rather than to treat and release
actions hospitals and communities              them. When patients “board” in the emergency department due to the
have taken to address crowding.                inability to transfer them elsewhere, the space, staff, and other resources
To conduct this work, GAO
                                               available to treat new emergency patients are diminished.
surveyed over 2,000 hospitals and
about 74 percent responded. The                Hospitals and communities reported a variety of actions to address
survey collected information on                crowding, including expanding their emergency departments and developing
crowding, such as data on                      ways to transfer emergency patients to inpatient beds more efficiently. For
diversion—that is, the extent to               the most part, these actions have not been extensively evaluated, so their
which hospitals asked ambulances               effect is unknown. However, the widely varying characteristics between
that would normally bring patients             hospitals mean that no one approach is likely to emerge as a way to address
to their hospitals to go instead to            this ongoing concern.
other hospitals that were
presumably less crowded.                       Representatives from the American College of Emergency Physicians and
                                               the American Hospital Association and an independent reviewer provided
                                               comments on a draft of this report, which we incorporated as appropriate.

                                               Hospitals by Percentage of Time on Diversion, Fiscal Year 2001




www.gao.gov/cgi-bin/getrpt?GAO-03-460.

To view the full report, including the scope
and methodology, click on the link above.
For more information, contact Janet Heinrich
on (202) 512-7119.
Contents


Letter                                                                                    1
               Results in Brief                                                           3
               Background                                                                 4
               Emergency Department Crowding Is More Pronounced in Some
                 Hospitals and Certain Types of Communities                               9
               Availability of Inpatient Beds for Emergency Patients Cited as a
                 Key Factor Contributing to Crowding, but Other Factors Also
                 Contribute                                                              22
               Wide Range of Activities Under Way to Manage Crowding at
                 Hospitals and in Communities, but Problems Persist                      32
               Concluding Observations                                                   38
               Comments from External Reviewers                                          39

Appendix I     Scope and Methodology                                                     41
               Survey of Hospitals                                                       41
               Site Visits                                                               44

Appendix II    Diversion Policies at the Six Locations GAO
               Visited                                                                   45



Appendix III   Select Results of GAO Survey of Hospitals
               Regarding Emergency Department Crowding                                   48



Appendix IV    GAO Contact and Staff Acknowledgments                                     64
               GAO Contact                                                               64
               Acknowledgments                                                           64



Tables
               Table 1: Indicators of Emergency Department Crowding                       6
               Table 2: Indicators of Crowding, by Population of MSA                     19
               Table 3: Indicators of Crowding, by Population Growth of MSAs             20
               Table 4: Indicators of Crowding, by Percentage of MSA Population
                        without Health Insurance                                         21
               Table 5: Indicators of Crowding, by Admissions per Bed in the MSA         25



               Page i                              GAO-03-460 Emergency Department Crowding
Table 6: Indicators of Crowding, by Percentage of Emergency
         Visits Resulting in Hospital Inpatient Admissions, Fiscal
         Year 2001                                                       26
Table 7: Indicators of Crowding, by Average Occupancy as a
         Percentage of Staffed Inpatient Beds, Fiscal Year 2001          27
Table 8: Examples of Expansions of Emergency Departments or
         Inpatient Capacity at Hospitals GAO Visited                     34
Table 9: Examples of Hospitals’ Increasing Efficiency                    35
Table 10: Diversion Task Force Activity                                  36
Table 11: Characteristics of Locations Selected for Site Visits          44
Table 12: Comparison of EMS Areas and Diversion Policies for Site
         Visit Locations                                                 46
Table 13: Characteristics of Hospitals in Survey Universe                49
Table 14: Hospitals by Volume of Emergency Department Patient
         Visits, Fiscal Years 1997 and 2001                              49
Table 15: Mean Number of Emergency Department Standard and
         Other Treatment Spaces and Increase in Treatment
         Spaces, Last Day of Fiscal Years 1997 and 2001                  50
Table 16: Hospitals Reporting Problems with On-Call Physician
         Specialty Coverage during Fiscal Year 2001                      50
Table 17: Specialty Areas for Which Hospitals Reported Having
         Problems with On-Call Physician Specialty Coverage in the
         Emergency Department during Fiscal Year 2001                    51
Table 18: Hospitals on Diversion, Fiscal Year 2001                       51
Table 19: Hospitals by Percentage of Time on Diversion, Fiscal
         Year 2001                                                       52
Table 20: Reasons Contributing to the Hospital Not Going on
         Diversion in Fiscal Year 2001                                   52
Table 21: Trauma Center Status and Diversion, Fiscal Year 2001           53
Table 22: Conditions Contributing to Hospitals Going on Diversion,
         Fiscal Year 2001                                                53
Table 23: Methods Hospitals Used to Minimize Diversion, Hospitals
         That Diverted in Fiscal Year 2001                               54
Table 24: Hospitals Reporting State or Local Laws or Rules That
         Restrict When Hospitals Can Go on Diversion                     54
Table 25: Hospitals’ Knowledge of When Other Hospitals Are on
         Diversion                                                       54
Table 26: Methods for Learning about Other Hospitals’ Diversion          55
Table 27: Type of Care the Hospital Was Unable to Receive or
         Accept for the Most Recent Episode of Diversion                 55
Table 28: Hospitals Boarding Patients 2 Hours or More, Past
         12 Months                                                       55



Page ii                            GAO-03-460 Emergency Department Crowding
          Table 29: Hospitals by Percentage of Patients Boarded 2 Hours or
                  More, Past 12 Months                                              56
          Table 30: Hospitals by Average Hours of Patients Boarding, Past
                  12 Months                                                         56
          Table 31: Conditions Contributing to Boarding Patients 2 Hours or
                  More in Past 12 Months                                            57
          Table 32: Hospitals by Percentage of Patients Who Left after Triage
                  but before a Medical Evaluation, Fiscal Year 2001                 57
          Table 33: Indicators of Crowding, by Number of Staffed Inpatient
                  Beds, Last Day of Fiscal Year 2001                                58
          Table 34: Indicators of Crowding, by Number of Emergency
                  Department Visits per Standard Treatment Space, Fiscal
                  Year 2001                                                         58
          Table 35: Indicators of Crowding, by Number of Emergency
                  Department Standard Treatment Spaces per Staffed
                  Inpatient Hospital Bed, Last Day of Fiscal Year 2001              59
          Table 36: Indicators of Crowding, by Emergency Department
                  Admissions per Staffed Inpatient Bed, Fiscal Year 2001            59
          Table 37: Indicators of Crowding, by Hospital Ownership                   60
          Table 38: Indicators of Crowding, by Trauma Center Status                 60
          Table 39: Indicators of Crowding, by Teaching Status                      61
          Table 40: Indicators of Crowding, by Select Payer Sources for
                  Emergency Department Visits, Fiscal Year 2001                     61
          Table 41: Hospitals Applying for Regulatory Approval to Increase
                  Licensed Beds, since Start of Fiscal Year 2001                    62
          Table 42: Types of Beds Requested since Start of Fiscal Year 2001         62
          Table 43: Average Proportion of Emergency Visits Covered by
                  Medicare, Medicaid and SCHIP, and Self-Pay, Fiscal
                  Year 2001                                                         63


Figures
          Figure 1: Hospitals by Percentage of Time on Diversion, Fiscal
                   Year 2001                                                        10
          Figure 2: Percentage of Hospitals on Diversion More than
                   10 Percent of the Time, by MSA, Fiscal Year 2001                 11
          Figure 3: Hospitals by Percentage of Patients Boarding 2 Hours or
                   More and Average Number of Hours Boarding, Past
                   12 Months                                                        12
          Figure 4: Percentage of Hospitals Boarding More than Half of
                   Patients for an Average of 8 Hours or More, by MSA               14




          Page iii                            GAO-03-460 Emergency Department Crowding
Figure 5: Hospitals by Percentage of Patients Who Left Before a
         Medical Evaluation, Fiscal Year 2001                                             15
Figure 6: Percentage of Hospitals with at Least 5 Percent of
         Patients Leaving before a Medical Evaluation, by MSA,
         Fiscal Year 2001                                                                 17
Figure 7: Conditions Hospitals Reported as Contributing to
         Diversion, Fiscal Year 2001                                                      23
Figure 8: Conditions Hospitals Reported as Contributing to
         Boarding Patients in the Past 12 Months                                          24
Figure 9: Primary Payer Source of Routine and Emergency
         Department Admissions, 2000                                                      30




Abbreviations

AHRQ              Agency for Healthcare Research and Quality
CCU               critical care unit
CAT               computed axial tomography
CT                computed tomography
DRG               diagnosis related group
EMS               emergency medical services
HHS               Department of Health and Human Services
ICU               intensive care unit
MRI               magnetic resonance imaging
MSA               metropolitan statistical area
SCHIP             State Children’s Health Insurance Program




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Page iv                                     GAO-03-460 Emergency Department Crowding
United States General Accounting Office
Washington, DC 20548




                                   March 14, 2003

                                   The Honorable Max Baucus
                                   Ranking Minority Member
                                   Committee on Finance
                                   United States Senate

                                   Dear Senator Baucus:

                                   Open 24 hours a day, 7 days a week, hospital emergency departments are a
                                   major part of the nation’s health care safety net. Emergency departments
                                   report being under increasing pressure, with the number of visits
                                   increasing about 14 percent from an estimated 95 million in 1997 to an
                                   estimated 108 million in 2000, and the number of hospitals with emergency
                                   departments decreasing by about 2 percent. This pressure has led to
                                   reports of crowding. For example, considerable attention has been given
                                   to reports that emergency departments request that ambulances that
                                   would normally bring patients to their hospitals go instead to other
                                   hospitals that are presumably less crowded—a practice known as
                                   diversion. Crowded conditions in emergency departments can also lead to
                                   long waits for care, which can prolong pain and suffering.

                                   There are no standard measures of the extent to which emergency
                                   departments are experiencing crowded conditions—hospital officials say
                                   “they know it when they see it.” However, there are several indicators that,
                                   according to experts, point to situations in which crowding is likely
                                   occurring. One indicator is the number of hours a hospital is on diversion
                                   status. A second indicator is the proportion of patients and the length of
                                   time patients “board” or remain in the emergency department—and
                                   therefore tie up space and staff resources—after a decision has been made
                                   to admit them as inpatients or transfer them to other facilities rather than
                                   releasing them. Finally, a third indicator is the proportion of patients who
                                   leave the emergency department before receiving a medical evaluation,
                                   generally because they tire of waiting.

                                   While considerable attention has been focused on this topic, much of it
                                   has centered on anecdotal reports or on data from a limited number of
                                   communities or emergency departments. You asked us to determine if
                                   data could be assembled from a broader, more national scope in order to
                                   provide more perspective on the issue. We conducted a review that
                                   encompassed hospitals located in the nation’s metropolitan statistical


                                   Page 1                              GAO-03-460 Emergency Department Crowding
    areas (MSA).1 We excluded nonmetropolitan areas because available
    information and contacts with rural health organizations indicated that
    emergency department crowding is not a major problem in these areas.
    Our work addressed the following questions:

•   To what extent are hospitals in MSAs experiencing crowded conditions in
    their emergency departments, and is crowding more severe in some types
    of MSAs than in others?
•   What factors contribute to emergency department crowding?
•   What actions have hospitals and communities taken to address crowding?

    To conduct this work, we sent a mail questionnaire to all community
    hospitals located in MSAs that reported having emergency departments in
    2000—more than 2,000 hospitals in all,2 of which about 74 percent
    responded. The survey collected information related to three indicators of
    crowding: (1) the number of hours on diversion, (2) the percentage of
    patients who were boarding in the emergency department for 2 hours or
    more and the average number of hours boarded, and (3) the proportion of
    patients who left before a medical evaluation.3 In analyzing these
    responses, we weighted responses to adjust for a lower response rate from
    investor-owned (for-profit) hospitals to provide estimates for the universe
    of hospitals. To examine which factors contributed to crowding, we
    analyzed information provided by the surveyed hospitals and other data on
    hospital and MSA characteristics. To provide information on actions taken
    by hospitals and communities to address crowding, as well as emergency
    medical services (EMS) systems and diversion at the community level, we
    conducted site visits in six locations where problems had been reported
    regarding crowded emergency departments—Atlanta, Boston, Cleveland,
    Los Angeles, Miami, and Phoenix. We selected these sites because they
    varied in geographic location, proportion of people without health
    insurance, population, and recent population growth. In these locations,
    we interviewed EMS officials, professional associations, and hospital


    1
     We focused on hospitals located in metropolitan areas designated as MSAs and primary
    metropolitan statistical areas by the U.S. Census Bureau. For purposes of this report, we
    will refer to both types of areas as MSAs. In 2000, MSAs accounted for about 80 percent of
    the nation’s population.
    2
     The hospitals that met our criteria were located in 321 MSAs. We also excluded federal
    hospitals, specialty hospitals, long-term care facilities, and hospitals located outside the 50
    states or the District of Columbia.
    3
     Many hospitals provided estimates for the three indicators. These estimates were used for
    our analyses.




    Page 2                                        GAO-03-460 Emergency Department Crowding
                   officials, and we observed emergency departments in 24 hospitals. We
                   supplemented this work with analysis of existing national data and
                   reviews of relevant studies. We also interviewed persons knowledgeable
                   about the issues, including health services researchers; representatives
                   from hospital associations, provider associations, and emergency medical
                   associations; and federal, state, and local health officials. Appendix I
                   explains our methodology in more detail. We conducted our work from
                   July 2001 through February 2003 in accordance with generally accepted
                   government auditing standards.


                   Although most emergency departments across the country experienced
Results in Brief   some degree of crowding, the problem is much more pronounced in some
                   hospitals and areas than in others. For example, while our nationwide
                   survey of hospitals found that about two of every three emergency
                   departments reported going on diversion at some point in fiscal year 2001,
                   a much smaller portion—nearly 1 of every 10 hospitals—was on diversion
                   more than 20 percent of the time. In general, hospitals that reported the
                   most problems with crowding were in the largest MSAs, MSAs with high
                   population growth, and MSAs with higher percentages of people without
                   health insurance. For example, hospitals in MSAs with populations of 2.5
                   million or more had a median of about 162 hours of diversion in 2001,
                   compared with about 9 hours for hospitals in MSAs with populations of
                   less than 1 million. Similarly, hospitals in MSAs with higher percentages of
                   uninsured people had almost twice as high of a median percentage of
                   patients leaving the emergency department prior to a medical evaluation
                   as those in MSAs with fewer uninsured.

                   Crowding is a complex issue and no single factor tends to explain why
                   crowding occurs. However, one key factor contributing to crowding at
                   many hospitals involves the inability to move patients out of emergency
                   departments and into inpatient beds when these patients must be admitted
                   to the hospital rather than released after treatment. With no inpatient beds
                   available for them, these patients then have to board in the emergency
                   department, reducing the emergency department’s ability to see additional
                   patients. In particular, hospitals that we surveyed and that we visited cited
                   the inability to move emergency patients into critical care or telemetry
                   (instrument-monitored) beds as contributing to crowding. Our analysis of
                   survey data found that indicators of emergency department crowding were
                   higher at hospitals in MSAs with more demand for inpatient hospital beds
                   and at hospitals with higher occupancy. Reasons given by hospital officials
                   and researchers we interviewed for not always having enough inpatient
                   beds to meet the demand from emergency patients included (1) economic


                   Page 3                               GAO-03-460 Emergency Department Crowding
             incentives to staff only the number of inpatient beds that will nearly
             always be full—a practice that limits a hospital’s ability to meet periodic
             spikes in demand, and (2) competition for available beds with scheduled
             admissions such as surgery patients. Other factors cited by researchers
             and hospital officials as contributing to crowding included closures of
             nearby hospitals and inadequate availability of physicians and other
             providers in the community.

             At the six sites we visited, hospitals and communities reported a variety of
             actions to address crowding. At hospitals, these actions generally fell into
             two categories—increasing capacity and increasing efficiency. For
             example, two-thirds of the hospitals we visited had expanded or planned
             to expand their emergency departments. Officials at some of the hospitals
             we visited also reported holding meetings of key hospital staff members to
             quickly identify and make available inpatient beds to minimize boarding in
             the emergency department. At the community level, actions included
             developing standard definitions and policies for when hospitals can go on
             diversion and improving communication among hospitals and EMS
             providers. However, the extent to which these actions address crowding is
             unknown. Hospital officials and others involved in these efforts said that
             their actions have helped better manage the problem of crowded
             emergency departments, but have not solved it. Some efforts are under
             way to better measure and track crowding at individual hospitals, which
             may facilitate future evaluation of efforts to address crowding.

             Representatives from the American College of Emergency Physicians and
             the American Hospital Association and an independent reviewer provided
             comments on a draft of this report, which we incorporated as appropriate.


             In 2000, about 3,900 nonfederal, general medical hospitals nationwide
Background   reported providing emergency care in emergency departments. Of these,
             just over half were located in MSAs. From 1997 through 2000, while the
             number of emergency department visits increased about 14 percent, the
             number of hospitals with emergency departments decreased by about 2
             percent. The result was that the average number of visits per emergency
             department increased by 16 percent.4 Many hospitals expanded the



             4
              L.F. McCaig and N. Ly, “National Hospital Ambulatory Medical Care Survey: 2000
             Emergency Department Summary,” Advance Data from Vital and Health Statistics, no.
             326 (Hyattsville, Md.: National Center for Health Statistics, 2002).




             Page 4                                  GAO-03-460 Emergency Department Crowding
physical space and number of treatment spaces in their emergency
departments during that time.

Recent reports have raised concern that many of the nation’s emergency
departments are experiencing high demand and crowded conditions. An
April 2002 report for the American Hospital Association, while limited in
scope and the proportion of hospitals responding, found that officials at
many hospitals in urban areas described their emergency departments as
operating at or above capacity.5 While there are no comprehensive studies
on the consequences of crowded conditions, health care researchers and
clinicians report that crowding has multiple effects, including prolonged
pain and suffering for some patients, long patient waits, increased
transport times for ambulance patients, inconvenience and dissatisfaction
for the patients and their families, and increased frustration among
medical staff.6 In addition to delays in treatment, some emergency
department directors have reported that patient care was compromised
and patients experienced poor outcomes as a result of crowded conditions
in emergency departments.7

Because the medical conditions of patients who come to the emergency
department can range from mild injuries such as ankle sprains to serious
traumas such as from automobile accidents—and can also include patients
with chronic conditions such as asthma or diabetes—the space,
equipment, and medical personnel resources required to treat patients
vary. As a result, there are no specific criteria, such as a ratio of patients to
staff, to define when an emergency department is too crowded and its
providers are overloaded. Rather, emergency department administrators
and physicians say “they know it when they see it.” In the absence of
specific criteria to define when an emergency department is crowded,
health care researchers suggest using several available indicators to point
to crowded conditions. Based on our review of studies and discussions
with experts, we chose three indicators of emergency department


5
 The Lewin Group, Emergency Department Overload: A Growing Crisis; The Results of
the AHA Survey of Emergency Department (ED) and Hospital Capacity, April 2002.
6
 EMS officials also report that in addition to longer ambulance transport times when
hospitals are on diversion, crowded emergency departments also tie up ambulance
providers while they wait to transfer their patients to the emergency department staff.
7
R. Derlet and others, “Frequent Overcrowding in U.S. Emergency Departments,” Academic
Emergency Medicine, vol. 8, no. 2 (2001), and S.K. Epstein and D. Slate, “The
Massachusetts College of Emergency Physicians Ambulance Diversion Survey” (abstract),
Academic Emergency Medicine, vol. 8, no. 5 (2001).




Page 5                                      GAO-03-460 Emergency Department Crowding
                                              crowding. As shown in table 1, all three are useful indicators but all three
                                              also have limitations.

Table 1: Indicators of Emergency Department Crowding

                                                                                                                    Our measure of this
 Indicator            Definition                     Usefulness                     Limitations                     indicator
 Diversion            Hospitals request that         For hospitals that can go      The number of hours on          Our survey asked if
                      ambulances bypass their        on diversion, it is an         diversion is a potentially      hospitals ever went on
                      emergency departments          indicator of how often         imprecise measure of            diversion in fiscal year
                      and transport patients that    these emergency                crowding because                2001a and the total
                      would have been                departments believe that       whether a hospital can go       number of hours they
                      otherwise taken to those       they cannot safely handle      on diversion and the            were on diversion for any
                      emergency departments          additional ambulance           circumstances under             reason in fiscal year 2001.
                      to other medical facilities.   patients.                      which it can do so vary         In the six sites we visited,
                                                                                    from location to location,      we collected available
                                                                                    according to both               data on diversion for
                                                                                    individual hospital policy      2000, 2001, and 2002.
                                                                                    and communitywide
                                                                                    guidelines or rules.
 Boarding             The decision to admit or       Patients boarding in the       Boarding can be used to         Our survey asked if
                      transfer an emergency          emergency department           indicate a hospital’s ability   hospitals ever boarded
                      patient has been made,         take space and resources       to move a patient out of        patients for 2 hours or
                      and the patient waits to       that could be used to treat    the emergency                   more. For those that did,
                      leave the emergency            other emergency                department and into an          we asked for the
                      department for a minimum       department patients.           inpatient bed; however, it      percentage of patients
                      period.                        Boarding is an indicator       is possible for an              boarded for 2 hours or
                                                     that an emergency              emergency department to         more and the average
                                                     department’s capacity to       be boarding several             number of hours patients
                                                     treat additional patients is   patients while also having      boarded in the past 12
                                                     diminished.                    available treatment             months.
                                                                                    spaces to see additional
                                                                                    patients that come to the
                                                                                    emergency department.
 Left before a        The number of patients         The most common reason         Since emergency                 Based on survey data, we
                                           b
 medical evaluation   who left after triage but      for patients leaving the       department staff triage         calculated the percentage
                      before a medical               emergency department           patients, those with            of patients who left after
                      evaluation as a                before being treated is        nonemergent conditions          triage but before a
                      percentage of emergency        excessive waiting time,        generally wait the longest      medical evaluation for
                      department visits.             which can occur when an        and may be most likely to       fiscal year 2001.
                                                     emergency department is        tire of waiting and leave
                                                     crowded and unable to          before receiving a medical
                                                     treat the patients waiting     evaluation.
                                                     to be seen in a reasonable
                                                     amount of time.

Source: GAO.
                                              a
                                              We asked hospitals to provide data for their fiscal year 2001.
                                              b
                                              The process of sorting patients based on their need for immediate medical treatment.




                                              Page 6                                           GAO-03-460 Emergency Department Crowding
Crowding Indicator 1:   One indicator of a crowded emergency department is the number of hours
Diversion               a hospital is on diversionary status. Under federal law, all hospitals that
                        participate in Medicare are required to screen—and if an emergency
                        medical condition is present, stabilize—any patient who comes to the
                        emergency department, regardless of the individual’s ability to pay.8 Under
                        certain circumstances where a hospital lacks staffing or facilities to accept
                        additional emergency patients, the hospital may place itself on
                        “diversionary status” and direct en route ambulances to divert to another
                        hospital.9 In general, hospitals ask EMS providers to divert ambulances to
                        other medical facilities because their emergency department staff are
                        occupied and unable to promptly care for new arrivals or specific services
                        within the hospitals, such as the intensive care units, are filled and unable
                        to accommodate the specialized needs of new ambulance arrivals.

                        While on diversion, hospitals must still treat any patients who arrive by
                        ambulance, and in some cases, local community protocols allow
                        ambulances to go to a hospital that is on diversion when the patient asks
                        to go to that hospital or if the patient needs immediate medical treatment.
                        In addition, even while on diversion, the emergency department is still
                        required to screen and treat nonambulance patients—those patients who
                        walk in or otherwise arrive at the hospital—and these patients make up
                        the vast majority of visits to the emergency department. The Department
                        of Health and Human Service’s (HHS) National Center for Health Statistics
                        estimates that in 2000 about 14 percent of emergency department visits
                        were made by patients who arrived by ambulance, while 78 percent of
                        visits were made by patients who arrived at the emergency department by
                        “walking in.” For the remaining visits, the patients were brought in by the
                        police or social services (1.5 percent), or the mode of arrival was unknown
                        (6.3 percent).10




                        8
                         42 U.S.C. 1395dd(a) (2000). Under certain circumstances, a hospital may also transfer an
                        emergency patient to another hospital. See U.S. General Accounting Office, Emergency
                        Care: EMTALA Implementation and Enforcement Issues, GAO-01-747 (Washington, D.C.:
                        June 22, 2001) for more information on this federal law.
                        9
                         See 42 C.F.R. § 489.24(b) (2002). Under federal regulation, a hospital may only deny access
                        to non-hospital-owned ambulances.
                        10
                            McCaig and Ly.




                        Page 7                                      GAO-03-460 Emergency Department Crowding
                           As a measure of crowding, diversion has limitations in that some hospitals,
                           even when crowded, do not have the option to divert ambulances due to
                           state or local regulations, because there are no other medical facilities
                           nearby, or because of individual hospital policies. Hospital practices may
                           vary regarding the threshold at which a hospital goes on diversion. Local
                           community or hospital policies may also differ regarding the length of time
                           a hospital may remain on diversion. (See app. II for the local community
                           policies for the six sites we visited). However, for those hospitals that can
                           go on diversion, it is an indicator of how often these emergency
                           departments believe they can no longer handle additional ambulance
                           patients.


Crowding Indicator 2:      A second indicator suggested by health care researchers is the number of
Boarding                   patients who are “boarding” in the emergency department. These patients
                           remain in the emergency department after the decision has been made to
                           admit them to the hospital or transfer them to another facility. Many
                           factors can contribute to the length of time a patient is boarded in the
                           emergency department, such as inpatient bed availability, staffing levels,
                           and the complexity of a patient’s condition. Regardless of the reason,
                           while waiting for an inpatient bed or transfer, these patients still require
                           care and take up treatment space, equipment, and staff time in the
                           emergency department, shrinking the department’s resources available to
                           treat other emergency patients. A limitation of using boarding as an
                           indicator is that many hospitals do not collect this information regularly
                           and can only estimate how often and how long patients board in their
                           emergency departments. In addition, it is possible that emergency
                           departments board patients while also having available treatment spaces
                           to see additional patients.


Crowding Indicator 3:      Finally, the proportion of patients who leave after triage but before
Leaving before a Medical   receiving a medical evaluation is another indicator suggested by health
Evaluation                 care researchers that could indicate a crowded emergency department.
                           Long waits in the emergency department can delay needed care and
                           contribute to an increase in the number of people who choose to leave the
                           emergency department before receiving a medical evaluation. A limitation
                           to this indicator is that, because emergency department staff triage
                           patients, those with nonemergent conditions generally wait the longest
                           and may be most likely to tire of waiting and leave before a medical
                           evaluation. However, relatively mild conditions could potentially become
                           more serious if patients do not receive needed medical care because they
                           leave the emergency department before being evaluated and treated. A


                           Page 8                               GAO-03-460 Emergency Department Crowding
                          study of the consequences of leaving the emergency department prior to a
                          medical evaluation at one public hospital found that 46 percent of those
                          who left were judged to need immediate medical attention, and 11 percent
                          who left were hospitalized within the next week.11


                          Although most emergency departments across the country reported some
Emergency                 degree of crowding on one or more of the three indicators, the problem is
Department Crowding       much more pronounced in some hospitals than in others. In addition,
                          hospitals in the largest metropolitan areas (those with populations of 2.5
Is More Pronounced        million or more), communities with high population growth, and
in Some Hospitals and     communities with above average percentages of people without health
                          insurance had higher levels of crowding.
Certain Types of
Communities

Indicators Show Varying   Analysis of responses to our nationwide survey showed substantial
Degrees of Crowding       variation in the degree of crowding reported across all three indicators—
Nationwide                diversion, boarding, and patients leaving before a medical evaluation.
                          Hospitals ranged from little or no crowding to crowding that persisted for
                          a substantial part of the time.

                          Diversion. In total, we estimate that about 2 of every 3 of the hospitals in
                          our survey universe went on diversion at least once during fiscal year
                          2001. We estimate that about 2 in every 10 of these hospitals were on
                          diversion for more than 10 percent of the time, and about 1 in every 10 was
                          on diversion for more than 20 percent of the time—or about 5 hours per
                          day.12 Figure 1 shows the variation in the amount of diversion reported by
                          hospitals in MSAs.




                          11
                           S. Baker and others, “Patients Who Leave a Public Hospital Emergency Department
                          Without Being Seen by a Physician,” Journal of the American Medical Association, vol.
                          266, no. 8 (1991).
                          12
                            If data were not available, we asked hospitals to provide their best estimates. We estimate
                          that about 45 percent of hospitals that went on diversion in fiscal year 2001 provided
                          estimates for the total number of hours that their emergency departments were on
                          diversion.




                          Page 9                                       GAO-03-460 Emergency Department Crowding
Figure 1: Hospitals by Percentage of Time on Diversion, Fiscal Year 2001




Note: Responses were weighted to provide estimates for the entire universe of 2,021 hospitals. Data
were missing for about 4 percent of hospitals.


Diversion varies greatly by MSA. Figure 2 shows each MSA and the share
of hospitals within the MSA that reported being on diversion more than 10
percent of the time—or about 2.4 hours or more per day—in fiscal year
2001. Of the 248 MSAs for which data were available,13 171 (69 percent)
had no hospitals reporting being on diversion more than 10 percent of the
time. By contrast, 53 MSAs (21 percent) had at least one-quarter of
responding hospitals on diversion for more than 10 percent of the time.




13
 The 248 MSAs include those MSAs for which (1) more than half of hospitals in the MSA
returned surveys and (2) of those hospitals that returned surveys, more than half provided
data on diversion hours.




Page 10                                         GAO-03-460 Emergency Department Crowding
Figure 2: Percentage of Hospitals on Diversion More than 10 Percent of the Time, by MSA, Fiscal Year 2001




                                         Note: Percentage of hospitals reflects those hospitals that responded to the survey; responses were
                                         not weighted to represent all hospitals in the MSA.
                                         a
                                          MSAs with a response rate of 50 percent or less or MSAs with 50 percent or more of data missing for
                                         responding hospitals. In 12 MSAs, no hospitals responded; these MSAs were excluded from the map.




                                         Page 11                                         GAO-03-460 Emergency Department Crowding
                                        Boarding. Boarding patients for 2 hours or more in the emergency
                                        department while waiting for an inpatient bed or transfer occurred to
                                        some extent at an estimated 9 of every 10 hospitals. As part of our survey,
                                        we examined what percentage of emergency patients who boarded spent 2
                                        hours or more in boarding status and the average number of hours
                                        patients boarded.14 As figure 3 shows, while many hospitals reported
                                        boarding less than 25 percent of boarded patients for 2 hours or more in
                                        the past 12 months, about one-third of them reported boarding 75 percent
                                        or more of their boarded patients for that long. About 1 in every 5
                                        hospitals reported an average boarding time in their emergency
                                        departments of 8 hours or more.

Figure 3: Hospitals by Percentage of Patients Boarding 2 Hours or More and Average Number of Hours Boarding, Past 12
Months




                                        Note: Responses were weighted to provide estimates for the entire universe of 2,021 hospitals. Data
                                        were missing for about 5 percent of hospitals on the percentage of patients boarded 2 hours or more
                                        and for about 11 percent of hospitals on the average number of hours boarded.




                                        14
                                          If data were not available, we asked hospitals to provide their best estimates. We estimate
                                        that about 74 percent of hospitals that boarded patients for 2 hours or more in the past 12
                                        months estimated the percentage of patients boarding, and about 74 percent estimated the
                                        average number of hours patients boarded.




                                        Page 12                                         GAO-03-460 Emergency Department Crowding
Boarding varies greatly by MSA. Figure 4 shows each MSA and the extent
to which responding hospitals within the MSA reported that of those
patients who boarded in the past 12 months, at least half spent 2 hours or
more in boarding status, and the average boarding time was 8 hours or
more. Of the 206 MSAs for which data were available on the percentage of
patients boarded and the average number of hours boarded,15 112 MSAs
(54 percent) had no hospitals reporting that they met these criteria. In
contrast, 52 of the 206 MSAs (25 percent) had at least one-fourth of
responding hospitals reporting that they boarded at least half of their
patients for 2 hours or more and had an average boarding time of at least 8
hours.




15
 The 206 MSAs include those MSAs for which (1) more than half of hospitals in the MSA
returned surveys and (2) of those hospitals that returned surveys, 50 percent or more
provided data on the percentage of boarded patients boarding for 2 hours or more and the
average number of hours boarded.




Page 13                                    GAO-03-460 Emergency Department Crowding
Figure 4: Percentage of Hospitals Boarding More than Half of Patients for an Average of 8 Hours or More, by MSA




                                         Note: Percentage of hospitals reflects those hospitals that responded to the survey; responses were
                                         not weighted to represent all hospitals in the MSA. Boarding data were for the past 12 months.
                                         a
                                          MSAs with a response rate of 50 percent or less or MSAs with 50 percent or more of data missing for
                                         responding hospitals. In 12 MSAs, no hospitals responded; these MSAs were excluded from the map.




                                         Page 14                                         GAO-03-460 Emergency Department Crowding
Patients Leaving before a Medical Evaluation. From our nationwide survey
of hospitals, we estimate that the median percentage of patients who left
after triage but before a medical evaluation in fiscal year 2001 was 1.4
percent. We estimate that about 39 percent of hospitals had from 1 to 3
percent of patients who left before medical a evaluation in fiscal year 2001
while about 7 percent of hospitals reported that 5 percent or more of
emergency department patients left before a medical evaluation (see fig.
5).16

Figure 5: Hospitals by Percentage of Patients Who Left Before a Medical Evaluation,
Fiscal Year 2001




Note: Responses were weighted to provide estimates for the entire universe of 2,021 hospitals. Data
were missing for about 7 percent of hospitals.




16
  If data were not available, we asked hospitals to provide their best estimates. We estimate
that about 34 percent of hospitals provided estimates of the number of patients who
completed triage in the emergency department but left before a medical evaluation during
fiscal year 2001.




Page 15                                         GAO-03-460 Emergency Department Crowding
Figure 6 shows each MSA and the extent to which hospitals within the
MSA reported at least 5 percent of patients leaving before a medical
evaluation. Of the 243 MSAs for which data were available on the
percentage of patients who left before a medical evaluation,17 183 MSAs
(75 percent) had no hospitals reporting that they met these criteria. In
contrast, 31 of the 243 MSAs (13 percent) had at least one-fourth of
responding hospitals reporting that at least 5 percent of patients left
before a medical evaluation in fiscal year 2001.




17
 The 243 MSAs include those MSAs for which (1) more than half of hospitals in the MSA
returned surveys and (2) of those hospitals that returned surveys, 50 percent or more
provided data on patients who left before a medical evaluation.




Page 16                                   GAO-03-460 Emergency Department Crowding
Figure 6: Percentage of Hospitals with at Least 5 Percent of Patients Leaving before a Medical Evaluation, by MSA, Fiscal
Year 2001




                                         Note: Percentage of hospitals reflects those hospitals that responded to the survey; responses were
                                         not weighted to represent all hospitals in the MSA.
                                         a
                                          MSAs with a response rate of 50 percent or less or MSAs with 50 percent or more of data missing for
                                         responding hospitals. In 12 MSAs, no hospitals responded; these MSAs were excluded from the map.




                                         Page 17                                         GAO-03-460 Emergency Department Crowding
Crowding More                  We analyzed our three crowding indicators across different MSA
Pronounced in Certain          characteristics, including population, population growth, and level of
Types of Communities           uninsurance. We found all three characteristics were associated with
                               reported levels of crowding.18

MSAs with Larger Populations   Hospitals in MSAs of 2.5 million or more people reported higher levels of
                               all three indicators—diversion, boarding, and patients leaving before a
                               medical evaluation—than hospitals in MSAs of less than 1 million people
                               (see table 2). In these larger areas, hospitals had a median of about 162
                               hours of diversion in 2001 compared with 9 hours for hospitals in areas
                               with a population of less than 1 million. Similarly, the median percentage
                               of patients boarding 2 hours or more was more than twice as high in large
                               MSAs—48 percent versus 23 percent.19 The median percentage of patients
                               who left before a medical evaluation was also higher, though not as
                               dramatically as for the two other indicators.




                               18
                                These characteristics may be associated with other MSA or hospital characteristics. Our
                               analysis was limited to examining the independent associations of MSA and hospital
                               characteristics and our three indicators of crowding.
                               19
                                 In looking at those hospitals on diversion for more than 10 percent of the time, 41 percent
                               of hospitals were located in MSAs with populations of 2.5 million or more people compared
                               to 27 percent in MSAs of less than 1 million people.




                               Page 18                                     GAO-03-460 Emergency Department Crowding
                            Table 2: Indicators of Crowding, by Population of MSA

                                                                                                 MSA population
                                                                                                  1 million or more
                                                                            2.5 million               but less than       Less than
                                Crowding indicators                            or more                    2.5 million      1 million
                                Median number of
                                hours on diversion in
                                                                                             a                        a
                                fiscal year 2001                            162 hours                      84 hours         9 hours
                                Median percentage of
                                patients boarded 2
                                hours or more in past
                                                                                             a
                                12 months                                           48%                         39%a           23%
                                Median percentage of
                                patients who left
                                before a medical
                                evaluation                                         1.6%a                      1.4%
                                                                                                                   a,b
                                                                                                                              1.3%
                                                                                                                                   b




                            Source: GAO survey of hospitals, 2002, and U.S. Census Bureau.

                            Note: Responses were weighted to provide estimates for the universe of hospitals.
                            a
                            No statistically significant difference between the medians for hospitals in MSAs of 1 million or more
                            but less than 2.5 million and hospitals in MSAs with populations of 2.5 million or more.
                            b
                            No statistically significant difference between the medians for hospitals in MSAs of less than 1 million
                            and hospitals in MSAs of 1 million or more but less than 2.5 million.


                            Our site visits show that crowding indicators vary not only across MSAs
                            but also between hospitals within MSAs. Four of the six locations we
                            visited (Atlanta, Los Angeles, Boston, and Phoenix) were in MSAs with
                            populations of over 2.5 million and we found variation among hospitals
                            within these communities. For example, the 10 major Boston hospitals
                            were on diversion for an average of 322 hours in 2001. However, 2 of the
                            10 hospitals accounted for nearly half of the diversion hours for the 10
                            hospitals, averaging nearly 800 hours of diversion each.

MSAs with High Population   Hospitals in communities with high population growth from 1996 through
Growth                      2000 reported higher levels of diversion and patients leaving before a
                            medical evaluation compared to hospitals in communities with lower
                            population growth (see table 3). The median number of hours of diversion
                            in fiscal year 2001 for hospitals in MSAs with a high percentage population
                            growth was about five times that for hospitals in MSAs with lower
                            percentage population growth. Similarly, the median percentage of
                            patients who left before a medical evaluation was significantly higher for
                            hospitals in MSAs with high population growth—1.7 percent—than for
                            those in MSAs with low population growth—1.0 percent. In addition, of
                            hospitals that reported at least 5 percent of patients leaving before a
                            medical evaluation in 2001, 31 percent were in communities with high


                            Page 19                                                      GAO-03-460 Emergency Department Crowding
                             population growth compared to 15 percent in communities with low
                             population growth.

                             Table 3: Indicators of Crowding, by Population Growth of MSAs

                                                                                              MSA population growth, 1996-2000
                                 Crowding indicators                                           Top 25 percenta     Bottom 25 percentb
                                 Median number of hours on
                                 diversion in fiscal year 2001                                       50 hours                10 hours
                                 Median percentage of patients
                                 boarded 2 hours or more in past
                                                                                                            c
                                 12 months                                                              33%                     22%c
                                 Median percentage of patients
                                 who left before a medical
                                 evaluation                                                             1.7%                    1.0%

                             Source: GAO survey of hospitals, 2002, and U.S. Census Bureau.

                             Note: Responses were weighted to provide estimates for the universe of hospitals.
                             a
                              Hospitals in the top 25 percent in terms of MSA population growth were located in MSAs with a
                             population increase of about 8.4 percent or more.
                             b
                              Hospitals in the bottom 25 percent in terms of MSA population growth were located in MSAs with a
                             population increase of less than about 2.9 percent.
                             c
                             No statistically significant difference between the medians for hospitals in the top and bottom
                             quartiles.


                             Two of the six locations we visited, Atlanta and Phoenix, were in MSAs
                             with high population growth from 1996 to 2000—16 percent and 18 percent
                             growth, respectively. Diversion hours varied among hospitals in these
                             communities. For example, in Phoenix, 5 of the 28 hospitals in the region
                             made up about 42 percent of the region’s diversion hours in 2001. Two of
                             these 5 hospitals with high rates of diversion were in the city’s central
                             sector. Hospitals in this sector were on diversion an average of 10 percent
                             of the time in 2001. By contrast, hospitals in the region’s northeast sector,
                             a more suburban area, had the lowest average rate of diversion—an
                             average of 3 percent of the time.

MSAs with Higher Levels of   Hospitals in communities with a higher percentage of people without
Uninsurance                  health insurance reported higher levels of diversion and patients leaving
                             before a medical evaluation (see table 4). For example, hospitals in MSAs
                             where the percentage of uninsured people was above average reported
                             having almost twice as many patients leave the emergency department
                             prior to a medical evaluation than those in MSAs where the percentage of
                             uninsured was below average. Our analysis of other national data indicate
                             that waiting times, which are reported to be the primary reason patients
                             leave the emergency department before a medical evaluation, were longer


                             Page 20                                                      GAO-03-460 Emergency Department Crowding
in communities with more uninsured people. For example, in 2000, waiting
times for nonemergent visits averaged about 25 minutes longer in
communities with high levels of uninsured people than in communities
with low levels of uninsured people (90 minutes versus 65 minutes).20

Table 4: Indicators of Crowding, by Percentage of MSA Population without Health
Insurance

                                                             Level of uninsurance in the MSA
                                                     Significantly above the Significantly below the
                                                             average level of         average level of
    Crowding indicators                                         uninsurance              uninsurance
    Median number of hours on
    diversion in fiscal year 2001                                        228 hours            72 hours
    Median percentage of patients
    boarded 2 hours or more in past
                                                                                     a
    12 months                                                                   42%              49%a
    Median percentage of patients
    who left before a medical
    evaluation                                                                  2.2%             1.2%

Source: GAO survey of hospitals, 2002, and UCLA Center for Health Policy Research.

Notes: GAO analysis of survey data and UCLA Center for Health Policy Research analysis of
uninsurance rates for 96 large MSAs (compared to the average for those MSAs) based on the 2000
and 2001 Current Population Survey. Analysis was limited to hospitals in these 96 large MSAs.
Responses were weighted to provide estimates for the universe of hospitals.
a
 No statistically significant difference between the median percentages for areas with above and
below average levels of uninsurance.


Of the six sites we visited, three (Los Angeles, Phoenix, and Miami) were
MSAs with significantly higher percentages of people without health
insurance. The crowding indicators varied among hospitals in these MSAs
with high levels of uninsurance. For example, the number of hours on
diversion in 2001 for hospitals in the Los Angeles MSA ranged from no
diversion at four hospitals to 6,186 hours—about 71 percent of the time—
at another hospital.21




20
 Our analysis was limited to 96 large MSAs for which data on the level of uninsurance were
available and used data on waiting times from the National Hospital Ambulatory Medical
Care Survey.
21
  In addition, the amount of time hospitals were on diversion varied between different parts
of the Los Angeles MSA. Of nine areas designated by the Los Angeles County EMS agency,
the percentage of time that hospitals were on diversion in 2001 ranged from 12 percent in
one area to more than 46 percent of the time in another area.




Page 21                                                       GAO-03-460 Emergency Department Crowding
Crowding More           We also analyzed differences across a wide range of hospital
Pronounced in Certain   characteristics, including the number of staffed beds; hospital ownership;
Types of Hospitals      teaching status; trauma center status; and the proportions of emergency
                        department visits covered by Medicare, Medicaid or the State Children’s
                        Health Insurance Program (SCHIP), or self-pay as the payer source. All
                        three indicators of crowding were significantly higher in hospitals with
                        more staffed beds and at teaching hospitals, while the median numbers of
                        hours on diversion were higher at hospitals designated as certified trauma
                        centers and at hospitals with fewer patients covered by Medicare. In
                        addition, we found that the median proportion of patients who left before
                        a medical evaluation was significantly higher in public hospitals than
                        private, not-for-profit hospitals, and in hospitals with more emergency
                        department visits covered by Medicaid and SCHIP or more patients who
                        were self-pay patients.22 (See app. III for additional information on the
                        indicators of crowding by select hospital characteristics).


                        No single factor stands out as the reason why crowding occurs. Rather, a
Availability of         number of factors, including many outside the emergency department, are
Inpatient Beds for      associated with crowding. In both the opinion of hospitals we surveyed
                        and of hospital officials we interviewed, the factor most commonly
Emergency Patients      associated with crowding was the inability to transfer emergency patients
Cited as a Key Factor   to inpatient beds once decisions had been made to admit them as hospital
                        patients rather than to release them after treatment. In looking at why
Contributing to         hospitals did not have the capacity to always meet the demand for
Crowding, but Other     inpatient beds from emergency patients, hospital officials, researchers,
Factors Also            and others pointed to (1) financial pressures leading to limited hospital
                        capacity to meet periodic spikes in demand for inpatient beds and
Contribute              (2) competition between admissions from the emergency department and
                        scheduled admissions such as surgery patients, who are generally
                        considered to be more profitable. Other factors cited as contributing to
                        crowding include closures of nearby hospitals or availability of physicians
                        and other providers in the community.




                        22
                         These characteristics may be associated with other hospital or MSA characteristics. Our
                        analysis was limited to examining the independent associations of hospital and MSA
                        characteristics and our three indicators of crowding.




                        Page 22                                    GAO-03-460 Emergency Department Crowding
Lack of Available Inpatient              The inability to transfer emergency patients to inpatient beds was the
Beds for Emergency                       condition that surveyed hospitals reported most often as contributing to
Patients the Most                        going on diversion and boarding patients. Even when treatment spaces are
                                         available in the emergency department, hospitals may go on diversion for
Commonly Cited Factor                    patients who will likely need instrument-monitored beds or critical care
                                         beds because these types of beds are full. As figure 7 shows, the most
                                         common types of beds that were unavailable were intensive care unit
                                         (ICU) or critical care unit (CCU) beds, followed by instrument-monitored
                                         (telemetry) beds. More than three-fourths of hospitals that went on
                                         diversion reported that the lack of ICU/CCU beds contributed to diversion
                                         to a moderate, great, or very great extent.

Figure 7: Conditions Hospitals Reported as Contributing to Diversion, Fiscal Year 2001




                                         a
                                          Responses were weighted to provide estimates for the entire universe of hospitals. Percentages are
                                         based on an estimated 1,389 hospitals going on diversion in fiscal year 2001.




                                         Page 23                                         GAO-03-460 Emergency Department Crowding
                                         Similarly, lack of inpatient beds was the dominant reason given for the
                                         need to board patients in the emergency room (see fig. 8). Of hospitals that
                                         boarded patients for 2 hours or more in the past 12 months, about 80
                                         percent cited the lack of telemetry or critical care beds as contributing to
                                         boarding to a moderate, great, or very great extent.

Figure 8: Conditions Hospitals Reported as Contributing to Boarding Patients in the Past 12 Months




                                         a
                                          Responses were weighted to provide estimates for the entire universe of hospitals. Percentages are
                                         based on an estimated 1,822 hospitals boarding patients for 2 or more hours in the past 12 months.


                                         Our analysis of data collected in our survey generally corroborates that a
                                         lack of inpatient beds plays a major role in contributing to emergency
                                         department crowding. We found that those hospitals in communities with
                                         higher demand for inpatient beds—as measured by admissions per
                                         inpatient bed—had higher indicators of crowding. As table 5 shows,
                                         hospitals that rank in the top 25 percent in terms of admissions per bed in
                                         the MSA had both significantly higher numbers of diversion hours and
                                         proportions of patients boarding 2 hours or more than hospitals in the
                                         bottom 25 percent of admissions per bed. For example, hospitals in the
                                         top 25 percent reported a median of 170 hours on diversion in fiscal year
                                         2001, compared with a median of 12 hours for hospitals in the lowest 25
                                         percent.




                                         Page 24                                         GAO-03-460 Emergency Department Crowding
Table 5: Indicators of Crowding, by Admissions per Bed in the MSA
                                                                                                              a
                                                                           Admissions per bed
                                                                                    b                   c
    Crowding indicators                                               Top 25 percent  Bottom 25 percent
    Median number of hours on diversion in
    fiscal year 2001                                                           170 hours                             12 hours
    Median percentage of patients boarded
    2 hours or more in past 12 months                                                  60%                              19%
    Median percentage of patients who left
    before a medical evaluation                                                      1.5%d                             1.2%
                                                                                                                            d




Source: GAO survey of hospitals, 2002, and American Hospital Association Annual Survey Database, Fiscal Year 2000.

Note: Responses were weighted to provide estimates for the universe of hospitals.
a
 Admissions per bed in short-term general medical and surgical community hospitals with emergency
departments in the MSA based on data from the American Hospital Association Annual Survey
Database, Fiscal Year 2000.
b
Hospitals in the top 25 percent in terms of admissions per bed in the MSA were located in MSAs with
more than 48.9 admissions per bed.
c
Hospitals in the bottom 25 percent in terms of admissions per bed in the MSA were located in MSAs
with fewer than 40.3 admissions per bed.
d
    No statistically significant difference in the medians for hospitals in the top and bottom quartiles.


Similarly, hospitals with more demand for inpatient beds from the
emergency department—that is, a higher proportion of emergency visits
resulting in hospital admission—also had higher indicators of crowding.
As table 6 shows, the quarter of hospitals with the highest percentages—
more than 19.7 percent—of emergency visits resulting in inpatient hospital
admission reported more diversion and boarding than the quarter of
hospitals with the smallest percentages—less than 11.8 percent—of
emergency visits resulting in admission.




Page 25                                                       GAO-03-460 Emergency Department Crowding
Table 6: Indicators of Crowding, by Percentage of Emergency Visits Resulting in
Hospital Inpatient Admissions, Fiscal Year 2001

                                                Percentage of emergency department patients
                                                          admitted to the hospital
                                                                    a                         b
    Crowding indicators                               Top 25 percent        Bottom 25 percent
    Median number of hours on
    diversion in fiscal year 2001                                144 hours                           4 hours
    Median percentage of patients
    boarded 2 hours or more in past
    12 months                                                          52%                                  9%
    Median percentage of patients
    who left before a medical
                                                                            c
    evaluation                                                        1.6%                             1.3%c

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals.
a
    Hospitals in the top 25 percent admitted more than 19.7 percent of emergency visits.
b
    Hospitals in the bottom 25 percent admitted fewer than 11.8 percent of emergency visits.
c
    No statistically significant difference in the medians for hospitals in the top and bottom quartiles.


Finally, our analysis found that hospitals with more patients per bed—
measured by the average occupancy in fiscal year 2001 as a percentage of
the total number of staffed inpatient beds on the last day of the fiscal
year—also had higher indicators of crowding in the emergency
department (see table 7).23




23
 For the average occupancy in fiscal year 2001, our analysis used information that
hospitals reported on their average daily census at midnight. While the census at midday
may be higher than at midnight, only an estimated 13 percent of hospitals provided data on
midday census.




Page 26                                                GAO-03-460 Emergency Department Crowding
                            Table 7: Indicators of Crowding, by Average Occupancy as a Percentage of Staffed
                            Inpatient Beds, Fiscal Year 2001

                                                                        Average occupancy as a percentage of staffed
                                                                                                    a
                                                                                      inpatient beds
                                                                                            b                        c
                                Crowding indicators                           Top 25 percent      Bottom 25 percent
                                Median number of hours on
                                diversion in fiscal year 2001                          101 hours                        6 hours
                                Median percentage of patients
                                boarded 2 hours or more in past
                                12 months                                                     55%                               9%
                                Median percentage of patients who
                                left before a medical evaluation                             1.5%                          1.0%

                            Source: GAO survey of hospitals, 2002.

                            Note: Responses were weighted to provide estimates for the universe of hospitals.
                            a
                             Average daily census reported at midnight for fiscal year 2001 as a percentage of the total number of
                            staffed beds reported as of the last day of fiscal year 2001. Excludes long-term care, labor and
                            delivery, and postpartum beds.
                            b
                             Hospitals in the top 25 percent had an average daily census of more than 80.8 percent of staffed
                            inpatient beds.
                            c
                             Hospitals in the bottom 25 percent had an average daily census of less than 57 percent of staffed
                            inpatient beds.


                            The conclusion that the availability of inpatient beds contributes to
                            crowding in emergency departments was reiterated at the hospitals we
                            visited on our site visits. At 19 of the 24 hospitals we visited, hospital
                            officials reported that the lack of inpatient beds and subsequent boarding
                            of emergency patients was a key factor contributing to crowding. In
                            addition, a 1-week survey conducted in Massachusetts found that
                            hospitals’ occupancy rates were higher when hospitals were on diversion.24


Several Reasons Cited for   When we examined why hospitals did not always have the inpatient
Hospitals Not Always        capacity to meet the demand for beds from emergency patients, hospital
Having Inpatient Capacity   administrators, researchers, and clinicians cited several reasons, including
                            (1) financial incentives to control costs and maximize revenue by staffing
to Meet Demand for Beds     inpatient beds at a point where they will nearly always be full—a practice
from Emergency Patients     that limits a hospital’s ability to meet periodic spikes in demand, and




                            24
                             Massachusetts Department of Public Health, The DPH Ambulance Diversion Survey:
                            February 1-7, 2001.




                            Page 27                                          GAO-03-460 Emergency Department Crowding
                                (2) competition between emergency department admissions and
                                scheduled admissions for available beds.25

Economic Factors Influence      One reason reported for the lack of inpatient beds was the financial
Hospitals’ Capability to Meet   pressures hospitals face to staff inpatient beds at a level where they will
Periodic Spikes in Demand       nearly always be full. This practice limits a hospital’s ability to meet
                                periodic spikes in demand. Hospital administrators, clinicians, and health
                                care researchers report that changes in the hospital economic climate
                                have contributed to this decline in “surge capacity.” For example, in a
                                report prepared for the Massachusetts Health Policy Forum, one health
                                policy researcher noted that the lower occupancy rates of the 1970s and
                                1980s became unacceptable in the 1990s when hospitals were increasingly
                                driven by market-based factors. In a market-based system, successful
                                hospitals run full, attract both elective and emergency patients, and are
                                staffed closer to average demand than to the peaks.26

                                Another factor sometimes cited that is related to insufficient bed capacity
                                involves staffing. Officials at some hospitals we visited said that they did
                                not staff more of the beds they already had or open new beds because they
                                were concerned they would not be able to staff them or could not afford
                                the cost of staffing them.27 These hospitals cited the costs and difficulties
                                recruiting nurses, particularly the cost of hiring nurses from agencies that
                                contract out nursing services. For example, officials at a Miami hospital
                                we visited that staffed only about two-thirds of the beds for which it was
                                licensed in 2001 said that they would lose money if they staffed more beds
                                because of the cost of contract nurses.




                                25
                                  A third reason cited by some hospital officials was that low profit margins make it
                                difficult to access capital to expand. However, we did not find any significant difference in
                                our three crowding indicators between those surveyed hospitals with the highest and
                                lowest average hospital margins reported for fiscal years 1997 to 1999.
                                26
                                 M. McManus, “Emergency Department Overcrowding in Massachusetts: Making Room in
                                our Hospitals,” The Massachusetts Health Policy Forum, no. 12 (2001).
                                27
                                 While our survey asked hospital officials to provide data on (1) the hours of emergency
                                department physician and other clinician patient care coverage in the emergency
                                department on a typical day in fiscal year 2001 and (2) data on the hospital and agency
                                (contract) nursing full-time equivalent staff in both the emergency department and the
                                general hospital on the last day of fiscal year 2001, a large proportion of missing data
                                prevented us from examining our three crowding indicators by hospital staffing levels.




                                Page 28                                      GAO-03-460 Emergency Department Crowding
Emergency Department      For the inpatient beds that are available, many researchers and hospital
Admissions Compete with   officials we interviewed reported that hospitals often balance admissions
Other Admissions          from emergency departments with scheduled admissions for surgical
                          procedures, which are generally considered more profitable. One reason
                          that admissions from the emergency department are considered to be less
                          profitable is because these admissions tend to be for medical conditions,
                          such as pneumonia, rather than for those procedures that are considered
                          more profitable. Available data from the Agency for Healthcare Research
                          and Quality’s (AHRQ) Healthcare Cost and Utilization Project, Nationwide
                          Inpatient Sample, show that of hospital admissions from the emergency
                          department in 2000, most were for medical conditions (such as pneumonia
                          and heart failure). Further, 19 of the 20 most prevalent diagnosis related
                          groups (DRG) for these admissions were for medical conditions. In
                          contrast, half of the 20 most common DRGs for admissions that were not
                          from the emergency department were for surgical procedures (such as
                          orthopedic surgery and cardiac pacemaker implantation).28

                          Many hospital officials and researchers also said that emergency
                          department patients are less profitable because a larger proportion of
                          emergency admissions are patients for whom the primary payer source is
                          self-pay, which includes the uninsured, or Medicaid, which is generally
                          considered to provide lower reimbursement. As shown in figure 9,
                          available data from AHRQ’s Healthcare Cost and Utilization Project show
                          that the proportion of admissions for uninsured patients or patients with
                          Medicaid as the primary payer source was higher for admissions from the
                          emergency department than for routine admissions in 2000. At the same
                          time, the proportion of admissions with private insurance as the primary
                          payer source was higher for routine admissions than for patients admitted
                          from the emergency department. Because self-pay patients and those
                          covered by Medicaid are viewed as providing lower reimbursement,
                          hospital officials and health care researchers said that hospitals have a
                          financial incentive to fill the limited number of available beds with
                          scheduled admissions rather than emergency department admissions.




                          28
                           This analysis is based on national estimates of discharges from nonfederal, short-term,
                          general medical and surgical hospitals with emergency departments and excluded neonatal
                          and maternal discharges.




                          Page 29                                   GAO-03-460 Emergency Department Crowding
Figure 9: Primary Payer Source of Routine and Emergency Department Admissions,
2000




Note: This analysis is based on national estimates of discharges from nonfederal, short-term, general
medical and surgical hospitals with emergency departments, and excludes neonatal and maternal
discharges.


In addition, some hospital officials reported that surgeons bring in
business that generates revenues for the hospital and that hospitals may
not want to cancel or reschedule elective surgeries—and disrupt their
surgeons and patients—in order to make beds available for emergency
department patients. This point was supported by our survey results—less
than one-third of hospitals that went on diversion in fiscal year 2001 (29
percent) reported that they had canceled any elective procedures to
minimize going on diversion.




Page 30                                          GAO-03-460 Emergency Department Crowding
Additional Factors Cited as   Hospital officials reported in both our survey and during our site visits that
Contributing to Crowding      other factors contributed to crowding as well, including increased demand
                              due to the closure of other hospitals and difficulties in accessing
                              physicians and other medical providers in the community. For example,
                              officials at one hospital we visited said that when two neighboring
                              hospitals closed in 1999 and 2000, their hospital experienced a significant
                              increase in emergency department visits and subsequent crowding. In
                              addition, officials at some of the hospitals we visited said they thought that
                              the availability of physicians and other services, such as psychiatric
                              services, in their communities affected crowding in one or more instances.
                              For example, in Cleveland, the county psychiatric mobile health unit
                              recently stopped taking patients in the late evening and on weekends,
                              increasing the amount of time the emergency department had to care for
                              psychiatric patients during those times. One Cleveland hospital we visited
                              reported that boarding times for patients awaiting assessment by this unit
                              had increased for patients who arrived late at night.

                              Another factor that many hospital officials we interviewed and other
                              experts reported as contributing to crowding was an increase in the
                              amount of time clinicians need to spend with each emergency department
                              patient or the amount of time the patient remains in the emergency
                              department before a decision is made to admit, transfer, or release him or
                              her. Emergency department physicians and researchers report that
                              emergency patients are older, have more complex conditions, and have
                              more treatment and tests provided in the emergency department than in
                              prior years because the standard for admitting them to the hospital has
                              been raised and medical practices have changed. For example, one
                              emergency department administrator said that patients with asthma are
                              now treated and monitored in the emergency department for several hours
                              before a decision is made whether to admit them to inpatient beds.
                              Similarly, with newer technology available, patients with chest pain may
                              remain and be monitored in the emergency department for several hours
                              before a decision is made whether to admit them. In addition, hospital
                              officials reported that the time it takes to receive laboratory and radiology
                              results creates delays in the emergency department. While available data
                              from HHS’s National Center for Health Statistics indicate significant
                              increases from 1992 through 2000 in the proportion of emergency
                              department visits that were for illnesses instead of injuries and the
                              proportion of visits in which computed axial tomography (CAT) scans and
                              magnetic resonance imaging (MRI) screenings were conducted, no




                              Page 31                              GAO-03-460 Emergency Department Crowding
                            national data are available showing whether the length of time emergency
                                                                                                 ,
                            patients remain in the emergency department has changed over time. 29 30


                            At the six sites we visited, actions to address emergency department
Wide Range of               crowding had been taken at both the hospital and community levels. Steps
Activities Under Way        taken by hospitals generally fell into two categories: (1) increasing
                            capacity and (2) improving the efficiency with which patients are
to Manage Crowding          treated—and if necessary, moved to inpatient beds. At the community
at Hospitals and in         level, EMS agencies, health care associations, and public agencies were
                            generally active to some degree in implementing communitywide policies
Communities, but            and computerized diversion tracking systems to help direct the flow of
Problems Persist            ambulance traffic and keep hospital staff and EMS providers informed
                            about which hospitals are on diversion. While hospital and community
                            officials reported some positive results for their efforts, they generally
                            described these efforts as attempts to manage crowding problems rather
                            than to substantially reduce them. The effects of these efforts have not
                            been widely studied, though several activities are now under way that may
                            help facilitate future evaluations.


Hospitals Expand Capacity   To accommodate increasing demand, a number of hospitals in all six of
and Increase Efficiency     the locations we visited reported having expanded or planning to expand
                            their emergency department or hospital inpatient capacity in terms of
                            space, staffing, and laboratory capability. For example, 16 of the 24
                            hospitals we visited reported having expanded or planning to expand their
                            emergency department treatment space. These expansion activities ranged
                            from adding stretchers in the hallway to accommodate more emergency


                            29
                              Data from the National Center for Health Statistics for 1992 to 2000 also showed that the
                            percentage of emergency department visits admitted to the hospital had not changed
                            significantly—about 12 percent of visits resulted in admissions in 2000. However, the same
                            data found that the percentages of emergency department visits referred to another
                            physician or clinic or with no follow-up planned had increased significantly to about 47
                            percent and 10 percent of visits, respectively, in 2000.
                            30
                              Although officials at several hospitals we visited reported that difficulty getting specialty
                            coverage for the emergency department may contribute to longer patient stays in the
                            emergency department while waiting for specialists to evaluate their condition, most
                            hospitals we surveyed did not believe that this problem contributed to crowding to a great
                            extent. While our survey found that 59 percent of hospitals reported problems with on-call
                            specialty coverage, only about 5 percent of hospitals that went on diversion reported that
                            lack of on-call specialty coverage contributed to diversion to a moderate, great, or very
                            great extent, and only 7 percent of hospitals that boarded patients reported that problems
                            with on-call coverage contributed to boarding to a moderate, great, or very great extent.




                            Page 32                                       GAO-03-460 Emergency Department Crowding
department patients to building new, larger emergency departments.31
Some hospitals added a unit—often referred to as a fast-track unit—to the
emergency department that is staffed with appropriate personnel, such as
nurse practitioners and physician assistants, to quickly treat nonurgent
cases. In addition, officials at 11 of the 24 hospitals we visited told us that
their hospitals had expanded or would be expanding inpatient capacity or
building new hospital facilities, a step that could make it easier to transfer
patients who need to be admitted as inpatients.32 We found expansions or
planned expansions at different types of hospitals, including not-for-profit,
public, and for-profit hospitals. At some hospitals that had recently
expanded their capacity, hospital officials reported that even though the
expansion helped, they continue to experience very crowded conditions.
Table 8 provides examples of the kinds of actions taken or planned at the
hospitals we visited.




31
  Many hospitals we visited and surveyed reported using nonstandard treatment spaces
such as stretchers in the hallway or chairs for treating emergency patients. Nineteen of the
24 hospitals we visited reported using nonstandard treatment spaces, and 78 percent of
hospitals in our survey reported having hallway treatment spaces and other nonstandard
treatment spaces at the end of fiscal year 2001.
32
 While 11 hospitals reported having expanded or planning to expand, 1 hospital in Los
Angeles reported plans to build a new, but smaller hospital inpatient facility to replace the
older, larger one. A hospital official cited financial pressures as the primary reason for
smaller capacity. Of the hospitals we surveyed, about 296 (15 percent) reported having
applied for an increased number of licensed beds since the beginning of fiscal year 2001. In
2002, 26 states and the District of Columbia required hospitals to apply for regulatory
approval to increase the number of hospital inpatient beds, according to the American
Health Planning Association.




Page 33                                      GAO-03-460 Emergency Department Crowding
Table 8: Examples of Expansions of Emergency Departments or Inpatient Capacity
at Hospitals GAO Visited



  Location                Actions taken by hospitals
  Atlanta                 One hospital has opened a new emergency department that increased
                          the number of standard treatment spaces from 17 to 33, including a
                          fast-track unit for treating nonurgent patients more quickly in the
                          emergency department. The hospital also plans to staff 80 additional
                          inpatient hospital beds.
  Cleveland               One hospital increased the number of emergency department beds
                          from 15 to 21 and added 12 ICU beds.
  Miami                   One hospital is expanding its emergency department to double the
                          number of treatment spaces from 24 to 48 beds. In addition, the
                          hospital recently added (1) a 40-bed temporary care unit to handle
                          patients boarding in the emergency department and (2) adult and
                          pediatric fast-track units in the emergency department to treat
                          nonurgent patients.
  Phoenix                 One hospital added additional physician coverage during the busiest
                          time of the day and added a fast-track unit to treat nonurgent patients
                          more quickly.

Source: GAO data from site visits to 24 hospitals in selected MSAs, 2002.



While more than two-thirds of the hospitals we visited were expanding or
reported having plans to expand their capacity, nearly all of the 24
hospitals we visited reported taking some type of action to increase the
flow of patients through the emergency department and to reduce the time
needed to place admitted emergency department patients into hospital
beds. When patients cannot be moved efficiently through the emergency
department and into inpatient hospital beds, they occupy emergency
department space, staff, and services and reduce the capacity that might
otherwise be available to treat other patients waiting to be seen in the
emergency department. As shown in table 9, hospitals’ approaches to
increase efficiency varied. For example, some hospitals focused on
increasing the speed of the registration and triage process, while others
were dependent on actions taken outside of the emergency department
and on inpatient floors of the hospital, such as having coordinating
committees or multidisciplinary teams that are directed to increase
availability of inpatient beds and reduce boarding.




Page 34                                                         GAO-03-460 Emergency Department Crowding
                       Table 9: Examples of Hospitals’ Increasing Efficiency

                        Location               Actions taken by hospitals
                        Atlanta                One hospital formed a “bed briefing group,” which meets three times a
                                               day to discuss the types of emergency department patients waiting for
                                               inpatient beds and the types of inpatient beds expected to become
                                               available. Attendees include representatives from the hospital inpatient
                                               units (e.g., medical/surgical beds, critical care beds), the emergency
                                               department, nursing administration, and environmental services.
                        Boston                 One hospital developed “Code Help ER,” under which all available staff
                                               resources are called on to expedite admissions and discharges when
                                               the hospital’s emergency department load is particularly high. Under this
                                               policy, priority is placed on transporting patients who have been
                                               boarding in the emergency department to inpatient beds, completing
                                               nursing reports, and cleaning beds before the hospital goes on
                                               diversion. After a “Code Help ER,” hospital officials conduct a review to
                                               determine the causes leading to that situation. Hospital officials recently
                                               completed the first analysis of the reviews and will be making
                                               recommendations for internal policy changes later this year. “Code Help
                                               ER” has been adopted by the state of Massachusetts as a best practice
                                               and is being used at other hospitals.
                        Miami                  One hospital implemented a program called, “Think Noon!” to encourage
                                               doctors and hospital staff to discharge patients from inpatient beds
                                               before noon of the discharge day. The objective of the program is to
                                               make room available for patients waiting for inpatient beds, including
                                               those boarding in the emergency department.
                        Phoenix                One hospital streamlined the registration process; changed the process
                                               for providing lab and radiology services; and implemented “Code
                                               Purple,” which is similar to “Code Help ER” that is used in Boston.

                       Source: GAO data from site visits to 24 hospitals in selected MSAs, 2002.




Community Activities   At the community level, efforts focused on ways to better manage
Focus on Systems to    crowding, particularly diversion, through task forces and development of
Manage Diversion       diversion policies and tracking systems. At three of the six sites we visited,
                       task forces had been formed to address these issues. The task forces
                       generally addressed crowding and diversion in three ways: assembling
                       stakeholders to examine causes, bringing attention to the issue, and
                       developing methods to manage the problem (see table 10).




                       Page 35                                                         GAO-03-460 Emergency Department Crowding
Table 10: Diversion Task Force Activity

 Location               Action taken                             Participants           Result
 Boston                 The Massachusetts Department             State health officials, health
                                                                                        Major accomplishments include the development
                        of Public Health started a               researchers, emergency of uniform guidelines and definitions for types of
                        Diversion Task Force in 1998.            department physicians, hospital
                                                                                        diversion. The Massachusetts Department of
                                                                 administrators, and EMS officials
                                                                                        Public Health conducted a survey for the task
                                                                                        force to study the reasons for the contributing
                                                                                        factors to emergency department crowding and
                                                                                        ambulance diversion in Massachusetts.
 Los Angeles            The Healthcare Association of   Hospital administrators and EMS The task force developed a list of 12 possible
                        Southern California convened a officials                        contributing factors or underlying causes for
                        task force in 2001 that focused                                 diversion and drafted a list of potential solution
                        on diversion.                                                   steps.
 Phoenix                The central Arizona regional    Hospital representatives,       This group facilitates EMS and hospital
                        EMS coordinating agency has a emergency department              discussions regarding diversion, developed
                        diversion task force that has   clinicians, public and private  protocols for diversion, and agreed on the use of
                        been meeting since 1995.        EMS officials, and state and    a diversion tracking system.
                                                        county health officials

Source: GAO data from site visits in selected MSAs, 2002.



                                                            Five of the six sites we visited had developed standard policies or
                                                            guidelines regarding diversion and operated or participated in electronic
                                                            systems for tracking ambulance diversion. The sixth site we visited—
                                                            Miami-Dade County—took a different approach. The largest EMS provider
                                                            in the area, the Miami-Dade Fire Rescue Department EMS Division, no
                                                            longer formally honors hospital requests for diversion.33 On March 31,
                                                            1999, this EMS agency implemented a new policy directing ambulances to
                                                            bring patients to the nearest appropriate hospital, citing concerns over the
                                                            increased number of hospital emergency room closures and a
                                                            compromised ability to deliver quality patient care.

                                                            For the five sites we visited that allowed diversion, each system improved
                                                            communication among hospital and EMS providers by (1) allowing
                                                            hospitals to request being put on diversion, (2) making hospitals aware of
                                                            other hospitals’ diversion status, and (3) making ambulance dispatchers
                                                            and ambulance drivers aware of which hospitals are on diversion. In these
                                                            locations, diversion systems are used to provide a structure to
                                                            systematically try to spread the ambulance volume during times of peak
                                                            demand by redirecting ambulances to hospitals that are presumably less



                                                            33
                                                              The second largest EMS agency in Miami-Dade County, the City of Miami Fire-Rescue
                                                            EMS, does have policies for diversion that govern its service area. See app. II for additional
                                                            information on the diversion policies of each site visited.




                                                            Page 36                                      GAO-03-460 Emergency Department Crowding
                            crowded. At three of these sites, EMS agencies produce reports on the
                            number of hours each hospital was on diversion each month.34 EMS
                            agencies, hospital associations, and government agencies use diversion
                            reports to review policies and monitor hospitals’ diversion hours.


Current Efforts Unable to   While some sites we visited have experienced limited improvement, efforts
Reverse Crowding Trends     under way have not made substantial reductions in the current extent of
                            crowding. Some officials we interviewed described their efforts as
                            attempts to manage the situation to keep it from getting worse rather than
                            solving the problem. For example, in Boston, officials from the
                            Massachusetts chapter of the American College of Emergency Physicians
                            who participate in their state’s diversion task force said they see diversion
                            as a Band-Aid for addressing what they believe is a crisis. They said that
                            while the task force has taken steps to better manage diversion, increased
                            demand for emergency department services due to events such as a bad
                            flu season or disaster could still tax the system beyond its capacity.

                            Community-level data tend to support the view that these efforts, while
                            perhaps helping to mitigate crowding, are not reversing the recent trends
                            in crowding. For example, from 2000 through 2001, the three sites we
                            visited that produce regular reports on diversion all experienced increases
                            in the percentage of time that their hospitals were on diversion. The
                            increase in the hours of diversion in these three locations ranged from 39
                            percent in the Los Angeles region to 73 percent in the Boston region.


Studies Assessing Impact    Despite the number of steps that hospitals and communities have taken,
of Current Efforts Have     few studies have been conducted on the effects of hospitals’ and
Been Limited but Other      communities’ efforts to address crowding. Only 1 of the 24 hospitals we
                            visited reported having completed an evaluation of the impact of its
Activities Are Under Way    activities. This hospital had implemented a program to increase efficiency
                            by discharging patients by noon and reported that its efforts resulted in
                            earlier placement of admitted emergency department patients in inpatient
                            beds. At the community level, while several communities monitor the
                            number of hours on diversion, they reported that no comprehensive


                            34
                             These three sites included Boston’s EMS region, Los Angeles County EMS, and Phoenix’s
                            EMS region. While Atlanta’s EMS region has a system to notify hospitals and EMS
                            providers when hospitals are on diversion, data reports that track diversions over time are
                            not yet available. Cleveland has 55 local EMS agencies and does not report on
                            communitywide diversion data regularly.




                            Page 37                                     GAO-03-460 Emergency Department Crowding
               evaluations have been completed on the impact of communitywide efforts
               to address crowding.

               Recent initiatives have been started by such organizations as the Joint
               Commission on Accreditation of Healthcare Organizations, AHRQ, and the
               Robert Wood Johnson Foundation that may help in future evaluations of
               crowding. These organizations have initiatives under way to further study
               crowding, develop hospital standards related to crowding, develop and
               test measures of crowding, provide technical assistance to hospitals, and
               evaluate potential steps to ease the problem. However, the results of these
               studies are not anticipated to be available until later in 2003 or 2004.


               Emergency department crowding is not an issue that can be solved in the
Concluding     emergency department alone. Rather, it is a complex issue that reflects the
Observations   broader health care market. It is clear that, as a key part of the health care
               safety net, emergency departments in many of the nation’s largest
               communities are under strain.

               Our work suggests that some aspects of the problem are hospital-specific,
               such as high numbers of emergency patients, lack of space, and delays in
               obtaining test results. In addition, crowding appears to reflect the inability
               of individual hospitals to meet the demand for inpatient beds, particularly
               critical care and telemetry beds, both from emergency patients who need
               to be admitted to the hospital and patients admitted for elective
               procedures. When hospitals cannot accommodate peaks in demand, either
               because they lack space or because they choose to operate at levels that
               allow little excess capacity, the result is that emergency departments will
               often board patients who are waiting for inpatient beds. When they do, the
               capacity of the emergency department to treat additional patients is
               diminished.

               While such issues as concerns about staffing inpatient beds and
               availability of other providers in the community are similar across
               communities, the solutions may differ by community and local health care
               market. For example, one community may face crowding in the emergency
               department largely because people have problems accessing physicians
               and other providers in the community, and potential solutions could
               involve steps to improve access to these other providers or establishing
               fast-track systems to treat nonurgent conditions in the emergency
               department. Another community may face crowding primarily because
               facilities have closed or populations have increased and there are too few
               hospital beds staffed and operated in the area. In this situation, the


               Page 38                              GAO-03-460 Emergency Department Crowding
                     solution could involve reopening beds in existing facilities that were not
                     set up and staffed. To address communitywide factors contributing to
                     crowding, hospitals may need to work collaboratively with other facilities
                     in their communities. Communitywide efforts such as task forces and
                     standardized procedures and diversion policies have improved
                     communications between hospitals and EMS providers and provided some
                     degree of sharing the load when multiple hospitals are crowded. However,
                     these efforts appear to only manage the problem of crowded conditions in
                     emergency departments, rather than eliminate it.

                     Adding capacity, for both the emergency departments and for inpatient
                     beds, has been suggested as a solution, but no one solution is likely to fit
                     all circumstances. Crowding is clearly worse in some communities and
                     hospitals than in others, and the specific reasons for crowding need to be
                     better understood, particularly at the local level.


                     Representatives from the American College of Emergency Physicians and
Comments from        American Hospital Association and an independent reviewer provided
External Reviewers   comments on a draft of this report. The American College of Emergency
                     Physicians stated that our methodology was comprehensive and
                     systematic and identified and documented the leading causes of
                     emergency department crowding. It also stated that while the crowding
                     problems may be more pervasive in large metropolitan areas, its members
                     had provided recent anecdotal information that indicates that the
                     crowding problem is now becoming a concern in rural areas. While it is
                     possible that some rural areas are becoming concerned about crowding,
                     our survey was limited to hospitals in MSAs because available information
                     and contacts with rural health organizations indicated that emergency
                     department crowding was not a major problem in these areas.

                     An independent reviewer who has conducted research on emergency
                     department crowding issues stated that the report was well done and
                     informative. This reviewer and the American Hospital Association
                     provided technical comments that we incorporated as appropriate.


                     As we agreed with your office, unless you publicly announce the contents
                     of this report earlier, we plan no further distribution of it until 14 days
                     from the date of this letter. We will then send copies to others who are
                     interested and make copies available to others who request them. In
                     addition, this report will be available at no charge on GAO’s Web site at
                     http://www.gao.gov.


                     Page 39                              GAO-03-460 Emergency Department Crowding
If you or your staff have any questions, please contact me at (202) 512-
7119. An additional GAO contact and the names of other staff members
who made major contributions to this report are listed in app. IV.

Sincerely yours,




Janet Heinrich
Director, Health Care—Public Health Issues




Page 40                             GAO-03-460 Emergency Department Crowding
                      Appendix I: Scope and Methodology
Appendix I: Scope and Methodology


                      To accomplish our objectives, we surveyed over 2,000 short-term
                      nonfederal, general medical and surgical hospitals with emergency
                      departments located in metropolitan statistical areas (MSA). These
                      hospitals are located in the 50 states and the District of Columbia. We
                      obtained and analyzed data using three indicators of emergency
                      department crowding: diversion, boarding, and patients who left before
                      receiving a medical evaluation. We also used several hospital and
                      community characteristics, including hospital ownership, admissions per
                      bed, community population and growth, and the proportion of patients in
                      the community without insurance. In addition, we visited six metropolitan
                      areas—Atlanta, Boston, Cleveland, Los Angeles, Miami, and Phoenix. In
                      these locations, we interviewed emergency medical services officials and
                      officials at 4 hospitals in each area, for a total of 24 hospitals. We also
                      interviewed (1) federal agency officials at the Department of Health and
                      Human Services’ (HHS) National Center for Health Statistics, Health
                      Resources and Services Administration, and Agency for Healthcare
                      Research and Quality (AHRQ), (2) health care researchers at organizations
                      such as the Council on Health Care Economics and Policy, the Robert
                      Wood Johnson Foundation, and the Joint Commission on Accreditation of
                      Healthcare Organizations, (3) representatives of national and local
                      professional associations such as the American Ambulance Association,
                      American Hospital Association, American College of Emergency
                      Physicians, Emergency Nurses Association, National Association of
                      Emergency Medical Services Physicians, and American Medical
                      Association, and (4) hospital administrators and clinicians. In addition, we
                      reviewed relevant studies and policy documents and analyzed information
                      from national databases, including HHS’s National Center for Health
                      Statistics’ National Hospital Ambulatory Medical Care Survey and AHRQ’s
                      Healthcare Cost and Utilization Project, and the Health Resources and
                      Services Administration’s Area Resource File. We conducted our work
                      from July 2001 through February 2003 in accordance with generally
                      accepted government auditing standards.



Survey of Hospitals
Survey Universe and   To address questions about the extent of diversion, boarding, and patients
Development           leaving before a medical evaluation at hospitals in MSAs, we mailed a
                      questionnaire to all 2,041 short-term, nonfederal, general medical and
                      surgical care hospitals that reported they had emergency departments and
                      were located in MSAs in the 50 states and the District of Columbia based
                      on data from the American Hospital Association’s Annual Survey


                      Page 41                             GAO-03-460 Emergency Department Crowding
                  Appendix I: Scope and Methodology




                  Database, Fiscal Year 2000. We mailed the questionnaires to the chief
                  administrator of each hospital in May 2002. Each hospital was asked to
                  report for the emergency department located at its main campus.

                  The survey included questions on the emergency department, such as
                  (1) whether the hospital went on diversion and, if so, the number of hours
                  on diversion in the hospital’s fiscal year 2001, (2) whether the hospital
                  boarded patients for 2 hours or more in the past 12 months and, if so, the
                  percentage of boarded patients who boarded 2 hours or more and the
                  average number of hours boarded, and (3) the number of emergency
                  department visits and the number of patients who left after triage but
                  before a medical evaluation in the hospital’s fiscal year 2001. It also
                  included questions on the general hospital, including the number of staffed
                  beds (excluding long-term care, labor and delivery, and postpartum beds)
                  as of the last day of the hospital’s fiscal year 2001.1 In developing these
                  questions, we reviewed the literature and prior surveys related to
                  crowding issues and conducted discussions with expert researchers. We
                  also pretested our questionnaire in person with officials at 10 hospitals
                  and refined the questionnaire as appropriate.


Response Rates    Of the initial universe of 2,041 hospitals, 18 had closed by 2002 and 2 did
                  not have emergency departments in fiscal year 2001, resulting in a final
                  universe of 2,021 hospitals. We conducted follow-up mailings and
                  telephone follow-up calls to nonrespondents. We obtained responses from
                  1,489 hospitals, for an overall response rate of about 74 percent.2


Survey Analysis   We analyzed the response rates from various categories of hospitals and
                  weighted responses to adjust for a lower response rate from investor-
                  owned (for-profit) hospitals so that our results would reflect the
                  nationwide mix of hospital types. We analyzed the information provided
                  by hospitals for three indicators of emergency department crowding—
                  diversion, boarding, and patients who left before a medical evaluation. In
                  many cases, hospitals provided estimates for these indicators. Specifically,



                  1
                   A third section included questions on emergency preparedness for mass casualty
                  incidents, which will be reported separately.
                  2
                   Questionnaires received after September 3, 2002, and those of hospitals that only returned
                  the section on emergency preparedness were not included in calculating our response rate
                  and were excluded from our analyses.




                  Page 42                                     GAO-03-460 Emergency Department Crowding
Appendix I: Scope and Methodology




we estimate that (1) of hospitals that went on diversion, about 45 percent
provided estimates for the number of hours on diversion in fiscal year
2001, (2) of hospitals that boarded patients for 2 hours or more in the past
12 months, about 74 percent provided estimates for the percentage of
patients boarding 2 hours or more and about 74 percent provided
estimates for the average number of hours patients boarded, and (3) about
34 percent of all hospitals provided estimates of the number of patients
who left after triage but before a medical evaluation. For those hospitals
that provided estimates, we used these estimates in our analyses.

We examined the extent of crowding in hospitals in MSAs, by different
MSA and hospital characteristics. We grouped MSAs by characteristics
such as U.S. Census Bureau population in 2000, population growth from
1996 to 2000, and the percentage of the population without health
insurance.3 We examined our indicators of crowding by hospital
characteristics such as the number of staffed beds on the last day of fiscal
year 2001; whether the hospital was public, private not-for-profit, or
investor-owned (for-profit); the hospital’s teaching status; whether it was a
certified trauma center; and the proportion of emergency department
visits covered by Medicare, Medicaid and the State Children’s Health
Insurance Program, and self-pay as the payer source. We compared the
medians of our three indicators of crowding across these characteristics.
In calculating the median number of hours on diversion and the median
percentage of patients boarding 2 hours or more, we considered hospitals
that did not go on diversion in fiscal year 2001 to have no hours of
diversion and hospitals that did not board any patients 2 hours or more to
have no percentage of patients boarding.

We also conducted analyses to determine key factors associated with
these indicators of crowding. We analyzed hospitals’ responses regarding
which key factors contributed to our indicators of crowding and examined
the medians for the crowding indicators grouped by admissions per bed in
the MSA, percentage of emergency visits resulting in hospital inpatient
admissions in fiscal year 2001, and the average daily census as a
percentage of the number of staffed beds in the hospitals’ fiscal year 2001.
In addition, we analyzed data from AHRQ’s Healthcare Cost and




3
 Our analysis of uninsurance rates in MSAs was limited to data from the UCLA Center for
Health Policy Research for 96 large MSAs based on the 2000 and 2001 Current Population
Survey.




Page 43                                    GAO-03-460 Emergency Department Crowding
                                                                Appendix I: Scope and Methodology




                                                                Utilization Project, Nationwide Inpatient Sample, 2000, on the payer
                                                                source of admissions.


                                                                We conducted site visits in six locations: Atlanta, Georgia; Boston,
Site Visits                                                     Massachusetts; Los Angeles, California; Cleveland, Ohio; Miami, Florida;
                                                                and Phoenix, Arizona. We selected the six sites judgmentally to include
                                                                locations that varied in geographic location, the proportion of people
                                                                without health insurance, MSA population, and recent population growth
                                                                (see table 11). In addition, media reports and other sources had indicated
                                                                that all six sites had reported problems with crowded emergency
                                                                departments.

Table 11: Characteristics of Locations Selected for Site Visits

                                                                                                                              Level of                Admissions per bed,
                                                                                                                              uninsurance                2000, by quartile
                            Geographic                             U.S. Census                Percentage change               compared to MSA               (1=bottom 25
                            location                           population—2000                 in MSA population              average, 2000-2001           percent, 4=top
 Location                   (Census division)                          (for MSA)                       1996-2000              (percentage)                    25 percent)
 Atlanta                    South Atlantic                             4,112,198                              16              Not significantly                      43.7
                                                                                                                              different (14)                           (2)
 Boston                     New England                                     3,406,829                                    5    Below (10)                             50.7
                                                                                                                                                                       (4)
 Cleveland                  East North Central                              2,250,871                                    1 Below (12)                                40.8
                                                                                                                                                                       (2)
 Los Angeles                Pacific                                         9,519,338                                    5 Above (25)                                46.0
                                                                                                                                                                       (3)
 Miami                      South Atlantic                                  2,253,362                                    7 Above (27)                                40.6
                                                                                                                                                                       (2)
 Phoenix                    Mountain                                        3,251,876                                   18 Above (18)                                53.4
                                                                                                                                                                       (4)

Source: U.S. Census Bureau, UCLA Center for Health Policy Research, and the American Hospital Association Annual Survey Database, Fiscal Year 2000.

                                                                Note: UCLA Center for Health Policy Research provided analysis of uninsurance rates for 96 large
                                                                MSAs based on the 2000 and 2001 Current Population Survey.


                                                                At the six locations, we visited four hospitals at each site (including
                                                                public, for-profit, and not-for-profit hospitals), interviewed hospital
                                                                administrators and emergency department clinicians, and observed
                                                                operations in the emergency departments. We also interviewed officials
                                                                from local EMS agencies, hospital associations, and other professional
                                                                associations and experts knowledgeable about emergency department
                                                                crowding.




                                                                Page 44                                                      GAO-03-460 Emergency Department Crowding
                  Appendix II: Diversion Policies at the Six
Appendix II: Diversion Policies at the Six
                  Locations GAO Visited



Locations GAO Visited

                  While all six locations we visited had local or regional regulations,
                  policies, or guidelines on ambulance diversion, these policies varied
                  among and within the locations.1 For example, the largest emergency
                  medical services (EMS) provider in the Miami area, the Miami-Dade Fire
                  Rescue Department EMS Division, stopped allowing hospitals to go on
                  ambulance diversion as of March 31,1999, though the smaller City of
                  Miami Fire-Rescue EMS agency did have policies for diversion.2 As shown
                  in table 12, the locations we visited illustrate the differences between
                  diversion policies of different communities and demonstrate how an
                  episode of diversion in one place differs from an occurrence of diversion
                  elsewhere.

              •   All six locations had defined types of diversion, including categories such
                  as overall saturation in the emergency department, diversion for trauma
                  cases only, diversion because a neurosurgeon was unavailable, diversion
                  because a computed tomography (CT) scanner was unavailable, or
                  diversion because of an internal disaster such as a power failure.
              •   Five of the locations had computer-based diversion systems in place at the
                  time of our visit that allowed EMS dispatchers and hospital officials to
                  check which hospitals, if any, in the EMS region were on diversion.
              •   All six locations had circumstances under which ambulances would take
                  patients to the nearest appropriate hospital, regardless of whether the
                  hospital was on diversion. For example, all six locations had policies to
                  take patients with unstable or critical conditions to the nearest hospital,
                  and four had policies that the patient’s request to go to a specific hospital
                  could override diversion in certain circumstances.
              •   Most of the locations had a specific period after which a hospital would
                  need to either reconfirm its diversion status or be automatically reopened
                  to ambulances. However, the policies regarding the time limits varied. For
                  example, 10 major Boston hospitals were automatically taken off diversion
                  after 2 hours, while hospitals in Atlanta could go on diversion for up to 8
                  hours before they would automatically be reopened to all ambulances. In
                  addition, hospitals in Boston, Phoenix, and Cleveland could be taken off of
                  diversion status if too many hospitals in their immediate area wanted to go
                  on diversion. For example, when two-thirds of hospitals in a given sector
                  in Phoenix are on diversion, all of the hospitals are required to reopen.




                  1
                  We will refer to regulations, policies, and guidelines as policies in this appendix.
                  2
                   For purposes of this appendix, we will refer to the policies of the City of Miami in
                  discussing the diversion policies in the Miami area.




                  Page 45                                      GAO-03-460 Emergency Department Crowding
                                             Appendix II: Diversion Policies at the Six
                                             Locations GAO Visited




Table 12: Comparison of EMS Areas and Diversion Policies for Site Visit Locations

                                                                     Site visited
                     Los Angeles         Phoenix         Miamia             Atlanta                   Boston              Cleveland
EMS areas            Los Angeles         Maricopa County City of Miami      Eight metro               Suffolk County      Cuyahoga
                     County                                                 Atlanta counties          and parts of        County
                                                                                                      three other
                                                                                                      counties
Types of diversion   -Emergency          -Emergency           Each hospital     -Emergency room -Emergency                -Full restriction
                      department          department          should have its    saturation            department         -Critical
                      saturation          saturation          own diversion     -Trauma                saturation          restriction/
                     -Trauma care        -Trauma              policies and       saturation            (advanced life      trauma
                     -Pediatric critical services             procedures        -Medical/              support or full)   -Critical
                      care                saturation          consistent with    surgical             -Internal            restriction/
                     -Neurosurgeon       -Facility internal   City of Miami      saturation            disaster            medical
                      unavailable         disaster            Fire-Rescue       -Intensive care                           -Treat and
                     -CT scanner                              EMS diversion      unit/critical care                        release only
                      unavailable                             guidelines         unit saturation                          -Full restriction
                     -Internal disaster                                         -Psychiatric                               except trauma
                                                                                 saturation
                                                                                -No available
                                                                                 beds
                                                                                -Neurosurgeon
                                                                                 unavailable
                                                                                -CT services
                                                                                 unavailable
                                                                                                    b
                                                                                -Internal disaster
Computer-based       Yes (1996)          Yes (1999)           No                Yes (2001)            Yes (2001)          Yes (2002)
diversion
communication and
tracking system
(year began)?
Time limits for      2 hours, unless     3 hours before       2 hours, unless   Hospitals choose      4 hours, unless     No time limits,
diversion—           the hospital        reevaluation is      the hospital      from 1 to 8 hours     hospitals           but diversion
automatic reopen     reenters            required             requests an       and are               update their        status checked
requirements         diversion status                         extension         automatically         diversion           twice daily
                                                                                taken off             status; 2-hour      around
                                                                                diversion status      limit for 10        8:00 a.m. and
                                                                                when that time        major Boston        8:00 p.m.
                                                                                expires unless        hospitals
                                                                                they reactivate
                                                                                status




                                             Page 46                                      GAO-03-460 Emergency Department Crowding
                                                               Appendix II: Diversion Policies at the Six
                                                               Locations GAO Visited




                                                                                               Site visited
                                 Los Angeles                Phoenix                 Miamia            Atlanta                     Boston              Cleveland
 Threshold for the               No threshold               All open when           No threshold      No threshold                At the              When all but one
 number of hospitals                                        two-thirds of                                                         discretion of       hospital in one
 on diversion at the                                        hospitals in one                                                      EMS officials,      of the four
 same time                                                  of four EMS                                                           but the guiding     county regions
                                                            sectors are on                                                        principle is that   are diverting the
                                                            diversion                                                             multiple            same types of
                                                                                                                                  contiguous          patients,
                                                                                                                                  hospitals shall     hospitals are
                                                                                                                                  not be on           forced open in 4-
                                                                                                                                  diversion at the    hour rotating
                                                                                                                                  same time           shifts
 Impact of patient               Patients who               Patient                 Patients who           Patients who           Patients with       Patient
 preference for a                request specific           preference is not       request specific       request specific       complex             preference is not
 specific hospital               hospitals may be           specified in the        hospitals may be       hospitals that are     medical             specified in the
                                 taken to those             diversion policy        taken to those         within a               histories related   diversion policy
                                 hospitals                                          hospitals              reasonable             to the event or
                                 regardless of                                      regardless of          distance may be        patients who
                                 diversion status,                                  diversion status,      taken to those         have been
                                 if they are                                        if they are not in     hospitals              recently
                                 sufficiently                                       a life-threatening     regardless of          discharged
                                 stable and the                                     status                 diversion statusc      from particular
                                 hospitals are                                                                                    hospitals may
                                 within a                                                                                         be taken to
                                 reasonable                                                                                       those hospitals
                                 distance                                                                                         regardless of
                                                                                                                                  diversion status
 Circumstances                   No diversion for           No diversion for No diversion for              No diversion for       No diversion for    No diversion for
 when ambulances                 -basic life                unstable, critical -basic life                 -cardiac               patients            -patients felt to
 do not divert                    support patients          patients or         support patients            arrest/distress       experiencing         be in extreme
                                 -advanced life             unstable medical -critical patients             patients              immediate life-      circumstances
                                  support patients          patients with       and stable                 -patients with         threatening         -patients in
                                  who exhibit an            airway or           advanced life               upper airway          situations           cardiac arrest or
                                  uncontrollable            ventilation         support patients            compromise                                 whose airways
                                  problem as                difficulties, etc.  if transport               -unstable patients     Level I and II       cannot be
                                  defined by                                    exceeds 10 or               as directed by        trauma centers       controlled by
                                  unmanageable                                  15 minutes,                 medical               are expected to      EMS personnel
                                  airway or                                     respectively                personnel             accept patients
                                  uncontrolled                                                                                    with multiple
                                  hemorrhage                                                                                      traumas at all
                                                                                                                                  times

Source: GAO data from site visits in selected MSAs, 2002.

                                                               Note: Diversion policies as of December 31, 2002.
                                                               a
                                                                Miami-Dade Fire Rescue Department EMS Division, the largest EMS provider in the area, stopped
                                                               honoring diversion requests as of March 31, 1999. The second largest EMS agency, the City of Miami
                                                               Fire-Rescue EMS, continues to honor diversion requests. Information provided is for the City of Miami
                                                               Fire-Rescue EMS.
                                                               b
                                                                   In Atlanta, diversion categories are guidelines, not policy.
                                                               c
                                                                In Georgia, patients are generally permitted to select the hospital to which they want to be
                                                               transported. Ga. Comp. R. & Regs. r. 290-5-30-.05 (2002).




                                                               Page 47                                               GAO-03-460 Emergency Department Crowding
              Appendix III: Select Results of GAO Survey of
Appendix III: Select Results of GAO Survey
              Hospitals Regarding Emergency Department
              Crowding


of Hospitals Regarding Emergency
Department Crowding
              This appendix summarizes the results from questions we asked short-term
              nonfederal, general medical and surgical hospitals in metropolitan
              statistical areas (MSA) in the United States that had emergency
              departments in 2000. We sent the questionnaire to 2,041 hospitals that met
              these criteria—20 did not have emergency departments in fiscal year 2001
              or were closed, for a total of 2,021 hospitals. We obtained responses from
              1,489 hospitals, for an overall response rate of about 74 percent. We
              weighted responses to adjust for a lower response rate from investor-
              owned (for-profit) hospitals to provide estimates representative of the
              entire universe of 2,021 hospitals in MSAs.

              The following tables show select survey information on characteristics of
              the survey universe (table 13), emergency department visits and treatment
              spaces (tables 14 and 15), specialty on-call coverage (tables 16 and 17),
              diversion (tables 18 through 27), boarding (tables 28 through 31), patients
              who left before a medical evaluation (table 32), indicators of crowding by
              hospital characteristics (tables 33 through 40), hospitals applying for
              regulatory approval to increase licensed beds (tables 41 and 42), and payer
              sources for emergency department visits (table 43).




              Page 48                                    GAO-03-460 Emergency Department Crowding
Appendix III: Select Results of GAO Survey of
Hospitals Regarding Emergency Department
Crowding




Table 13: Characteristics of Hospitals in Survey Universe

    Hospital characteristic                                     Number of hospitals                          Percentage
    All hospitals                                                            2,021                                  100
    Population of hospital’s MSA
       2.5 million or more                                                                565                              28
       1 million to less than 2.5 million                                                 562                              28
       Less than 1 million                                                                894                              44
                                             a
    Level of uninsurance of hospital’s MSA
       Above average of 96 MSAs                                                           354                              18
       Below average of 96 MSAs                                                           633                              31
       Not significantly different from average
       of 96 MSAs                                                                         362                              18
       No data available                                                                  672                              33
    Certified trauma center?
       Yes                                                                               809                               40
       No                                                                              1,212                               60
    Ownership type
       Private, not-for-profit                                                         1,466                               73
       Investor-owned (for-profit)                                                       311                               15
       Public (nonfederal)                                                               244                               12
    Teaching hospital?
       Yes                                                                               697                               34
       No                                                                              1,324                               66

Source: GAO survey of hospitals, 2002; U.S. Census Bureau; UCLA Center for Health Policy Research; and American Hospital
Association Annual Survey Database, Fiscal Year 2000.
a
Level of uninsurance compared to the average for 96 large MSAs based on analysis by the UCLA
Center for Health Policy Research using data from the 2000 and 2001 Current Population Survey.



Table 14: Hospitals by Volume of Emergency Department Patient Visits, Fiscal
Years 1997 and 2001

                                                   1997                                          2001
    Number of emergency                   Number of                                     Number of
    department visits                      hospitals Percentage                          hospitals    Percentage
    Less than 25,000                            840          42                               696             34
    25,000 to less than
    50,000                                          783                    39                      924                     46
    50,000 to less than
    75,000                                          178                      9                     276                     14
    75,000 or more                                   43                      2                      99                      5
    Data missing                                    177                      9                      26                      1
Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages may
not add to 100 due to rounding.




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                                         Hospitals Regarding Emergency Department
                                         Crowding




Table 15: Mean Number of Emergency Department Standard and Other Treatment Spaces and Increase in Treatment Spaces,
Last Day of Fiscal Years 1997 and 2001

                                             1997                                    2001                        1997 to 2001
                                                                                                                 Mean
                                                      Number of                           Number of         percentage     Number of
 Type of treatment space                 Mean          hospitals            Mean          hospitals           increase       hospitals
 Standard (e.g., beds or
 treatment spaces specifically
 designed for emergency patients
 to receive care)                        17.7                 1,927                20.8         1,991                21.9       1,919
 Other (e.g., stretchers in
 hallway, chairs)                          5.7                1,718                 7.8         1,824                35.2       1,295

Source: GAO survey of hospitals, 2002.

                                         Note: Responses were weighted to provide estimates for the universe of hospitals.



                                         Table 16: Hospitals Reporting Problems with On-Call Physician Specialty Coverage
                                         during Fiscal Year 2001

                                          Did emergency department
                                          encounter any problems with
                                          on-call coverage?                               Number of hospitals Percentage of hospitals
                                          Yes                                                          1,201                      59
                                          No                                                             781                      39
                                          Data missing                                                    39                        2

                                         Source: GAO survey of hospitals, 2002.

                                         Note: Responses were weighted to provide estimates for the universe of hospitals.




                                         Page 50                                            GAO-03-460 Emergency Department Crowding
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Table 17: Specialty Areas for Which Hospitals Reported Having Problems with On-
Call Physician Specialty Coverage in the Emergency Department during Fiscal Year
2001

 Specialty area                             Number of hospitals                     Percentage
 Anesthesiology                                              64                              5
 Cardiology                                                127                              11
 Cardio/thoracic surgery                                   106                               9
 Ear, nose, and throat                                     332                              28
 General surgery                                           164                              14
 Neurology                                                 239                              20
 Neurosurgery                                              504                              42
 Orthopedics                                               401                              33
 Pediatrics                                                110                               9
 Plastic surgery                                           505                              42
 Psychiatry                                                381                              32
 Other (1)                                                 340                              28
 Other (2)                                                   52                              4

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages are
based on an estimated 1,201 hospitals that reported problems with on-call coverage. Some hospitals
reported multiple specialties.



Table 18: Hospitals on Diversion, Fiscal Year 2001

 Hospital on diversion in fiscal
 year 2001?                                 Number of hospitals                     Percentage
 Yes                                                     1,389                              69
 No                                                        614                              30
 Data missing                                                18                              1

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals.




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                                               Appendix III: Select Results of GAO Survey of
                                               Hospitals Regarding Emergency Department
                                               Crowding




                                               Table 19: Hospitals by Percentage of Time on Diversion, Fiscal Year 2001

                                                Percentage of time on diversion                 Number of hospitals Percentage of hospitals
                                                Greater than 20 percent                                          179                      9
                                                More than 10 and up to 20 percent                                146                      7
                                                More than 5 and up to 10 percent                                 157                      8
                                                Up to 5 percent                                                  839                     42
                                                Did not go on diversion                                          614                     30
                                                Data missing                                                      85                      4

                                               Source: GAO survey of hospitals, 2002.

                                               Note: Responses were weighted to provide estimates for the universe of hospitals.



Table 20: Reasons Contributing to the Hospital Not Going on Diversion in Fiscal Year 2001

                                                      Yes                                         No                     Data missing
 Reason for not going on                 Number of                                      Number of                     Number of
 diversion                                hospitals         Percentage                   hospitals   Percentage        hospitals Percentage
 Adequate hospital capacity made
 diversion unnecessary                         358                        58                  177           29                  80              13
 Only hospital serving large
 geographic area                               178                        29                  332           54                104               17
 Other hospitals on diversion                  104                        17                  383           62                127               21
 Administrative decision by
 emergency department to accept
 all ambulances                                346                        56                  170           28                  99              16
 Administrative decision by
 hospital to accept all ambulances             398                        65                  122           20                  94              15
 Diversion requires approval from
 outside the hospital and the
 request was denied                             10                          2                 469           76                135               22
 Diversion requires approval from
 outside the hospital and was not
 worth requesting—it would have
 been denied anyway                               9                         1                 473           77                132               22
 State or local law or regulation
 prohibits diversion                            24                          4                 465           76                125               20

Source: GAO survey of hospitals, 2002.

                                               Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages are
                                               based on an estimated 614 hospitals that did not go on diversion in fiscal year 2001. Some hospitals
                                               reported multiple reasons.




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                                                      Hospitals Regarding Emergency Department
                                                      Crowding




                                                      Table 21: Trauma Center Status and Diversion, Fiscal Year 2001

                                                       Was hospital that went on diversion                           Number of
                                                       designated as a certified trauma center?                       hospitals            Percentage
                                                       Yes                                                                 426                     31
                                                       No                                                                  929                     67
                                                       Data missing                                                          33                     2

                                                      Source: GAO survey of hospitals, 2002.

                                                      Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages are
                                                      based on an estimated 1,389 hospitals that went on diversion in fiscal year 2001.



Table 22: Conditions Contributing to Hospitals Going on Diversion, Fiscal Year 2001

                                                                              Number of hospitals (Percentage)
                                         Very great          Great           Moderate       Some          Little or                Not         Missing
 Condition                                   extent         extent             extent      extent       no extent           applicable            data
 Inability to transfer to
 intensive care unit/critical                  527              353                   189       134                 73                77              38
 care unit (ICU/CCU beds)                      (38)             (25)                  (14)      (10)               (5)               (6)             (3)
 Inability to transfer to                      476              329                   185       101                 99              138               59
 telemetry beds                                (34)             (24)                  (13)       (7)               (7)              (10)             (4)
 Emergency department                          523              276                   141       130               164               104               52
 capacity exceeded                             (38)             (20)                  (10)       (9)              (12)               (7)             (4)
 Inability to transfer to                      229              235                   253       187               202               193               89
 other inpatient beds                          (17)             (17)                  (18)      (13)              (15)              (14)             (6)
 Inability to transfer to                        43               44                  105       176               535               397               88
 other facilities                               (3)              (3)                   (8)      (13)              (39)              (29)             (6)
 Inability to transfer to                        45               33                    49        86              499               531             146
 pediatric beds                                 (3)              (2)                   (4)       (6)              (36)              (38)            (10)
 Concern emergency
 department would be
 overloaded due to other                        15                36                    48       70               571               541             108
 hospitals’ diversion                           (1)               (3)                   (3)      (5)              (41)              (39)             (8)
 Lack of on-call physician
 specialty coverage for                         24               18                    26        58               614               551              99
 emergency department                           (2)              (1)                   (2)       (4)              (44)              (40)             (7)
 Internal disaster (e.g.,                       21                 4                     5       27               615               604             111
 power failure)                                 (2)            (0.3)                 (0.4)       (2)              (44)              (44)             (8)

Source: GAO survey of hospitals, 2002.

                                                      Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages are
                                                      based on an estimated 1,389 hospitals going on diversion in fiscal year 2001 and may not add to 100
                                                      due to rounding. Some hospitals reported multiple conditions.




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Table 23: Methods Hospitals Used to Minimize Diversion, Hospitals That Diverted in
Fiscal Year 2001

                                                                   Number of
                                                              hospitals using
 Methods used to minimize going on diversion                     this method        Percentage
 Staff worked overtime                                                  1,142               82
 Opened inpatient beds in other areas of emergency
 department or hospital                                                     823               59
 Canceled elective procedures                                               403               29
 Used on-call system for additional staff                                   652               47
 Moved patients to other facilities                                         358               26
 Used hospital float pool for additional staff                              732               53
 Used overflow or holding areas for patients                                905               65
 Other                                                                      221               16
 No particular method was used                                               80                6

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages are
based on an estimated 1,389 hospitals going on diversion in fiscal year 2001. Some hospitals
reported multiple methods.



Table 24: Hospitals Reporting State or Local Laws or Rules That Restrict When
Hospitals Can Go on Diversion

 State or local laws or rules restricting
 when the emergency department/hospital                        Number of
 can go on diversion?                                           hospitals            Percentage
 Yes                                                                 624                     45
 No                                                                  733                     53
 Data missing                                                          32                     2

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages are
based on an estimated 1,389 hospitals going on diversion in fiscal year 2001.



Table 25: Hospitals’ Knowledge of When Other Hospitals Are on Diversion

 Emergency department or hospital knows                          Number of
 when other area hospitals are on diversion?                      hospitals          Percentage
 Yes                                                                 1,328                   96
 No                                                                      48                   3
 Data missing                                                            13                   1

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages are
based on an estimated 1,389 hospitals going on diversion in fiscal year 2001.




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Crowding




Table 26: Methods for Learning about Other Hospitals’ Diversion

 How emergency department or hospital
 knows when other area hospitals are on                        Number of
 diversion                                                      hospitals           Percentage
 Internet site                                                       415                    31
 Telephone or radio alert from other hospitals                       570                    43
 Telephone or radio alert from emergency
 medical services                                                      519                     39
 Word of mouth (e.g., ambulance drivers)                               458                     35
 Other                                                                 195                     15

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages are
based on an estimated 1,328 hospitals going on diversion in fiscal year 2001 that knew when other
hospitals were on diversion. Some hospitals reported multiple methods.



Table 27: Type of Care the Hospital Was Unable to Receive or Accept for the Most
Recent Episode of Diversion

 Type of care unable to accept               Number of hospitals                    Percentage
 Acute care (medical/surgical)                              626                             45
 Telemetry                                                  719                             52
 Intermediate (step-down)                                   471                             34
 Critical (ICU/CCU)                                         914                             66
 Trauma                                                     434                             31
 Pediatric                                                  313                             23
 Psychiatric                                                313                             23
 Other                                                      240                             17

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages are
based on an estimated 1,389 hospitals going on diversion in fiscal year 2001. Some hospitals
reported multiple types of care.



Table 28: Hospitals Boarding Patients 2 Hours or More, Past 12 Months

 Boarded patients for 2 hours or
 more in the past 12 months?                       Number of hospitals              Percentage
 Yes                                                            1,822                       90
 No                                                               173                        9
 Data missing                                                       26                       1

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals.




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Crowding




Table 29: Hospitals by Percentage of Patients Boarded 2 Hours or More, Past 12
Months

 Percentage of patients boarded
 2 hours or more                           Number of hospitals         Percentage of hospitals
 75 percent or more                                       630                               31
 50 percent to less than 75 percent                       260                              13
 25 percent to less than 50 percent                       200                              10
 Less than 25 percent                                     651                              32
 Did not board any patients 2 hours
 or more                                                       173                                  9
 Data missing                                                  107                                  5

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals. Hospitals were
asked what percentage of all the patients boarded in the past 12 months boarded for 2 hours or more.



Table 30: Hospitals by Average Hours of Patients Boarding, Past 12 Months

 Average number of hours
 patients boarded                          Number of hospitals        Percentage of hospitals
 8 hours or more                                          399                              20
 6 to less than 8 hours                                   266                              13
 4 to less than 6 hours                                   371                              18
 Less than 4 hours                                        593                             29
 Did not board any patients
 2 hours or more                                               173                                  9
 Data missing                                                  219                                 11

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals. Hospitals that
boarded patients 2 hours or more in the past 12 months were asked the average number of hours
that a patient was boarded, including those patients boarded for less than 2 hours.




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                                         Appendix III: Select Results of GAO Survey of
                                         Hospitals Regarding Emergency Department
                                         Crowding




Table 31: Conditions Contributing to Boarding Patients 2 Hours or More in Past 12 Months

                                                                Number of hospitals (percentage)
                           Very great            Great           Moderate         Some Little or no                 Not             Data
Condition                      extent           extent             extent        extent        extent        applicable          missing
Inability to transfer to          855              427                193            103           64                98               82
telemetry beds                   (47)             (23)               (11)             (6)         (3)                (5)              (5)
Inability to transfer to
critical care                     775              418                     279      178              63               37                72
(ICU/CCU beds)                    (43)             (23)                    (15)     (10)             (3)              (2)               (4)
Inability to transfer to          494              383                     341      219             135              124               126
other inpatient beds              (27)             (21)                    (19)     (12)             (7)              (7)               (7)
Emergency
department capacity               276              189                     179      207             490              277              204
exceeded                          (15)             (10)                    (10)     (11)            (27)             (15)             (11)
Inability to transfer to          149              157                     213      297             489              224              293
other facilities                   (8)              (9)                    (12)     (16)            (27)             (12)             (16)
Inability to transfer to          114                61                    108      188             643              510              198
pediatric beds                     (6)              (3)                     (6)     (10)            (35)             (28)             (11)
Lack of on-call
physician specialty
coverage for
emergency                          27                26                      71     189             784              524              202
department                         (2)               (1)                     (4)    (10)            (43)             (29)             (11)

                                         Source: GAO survey of hospitals, 2002.

                                         Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages are
                                         based on an estimated 1,822 hospitals boarding patients for 2 hours or more in the past 12 months
                                         and may not add to 100 due to rounding.



                                         Table 32: Hospitals by Percentage of Patients Who Left after Triage but before a
                                         Medical Evaluation, Fiscal Year 2001

                                          Percentage of patients who left
                                          after triage but before a medical
                                          evaluation                                 Number of hospitals Percentage of hospitals
                                          5 percent or more                                         133                        7
                                          More than 3 to less than 5 percent                        244                      12
                                          1 to 3 percent                                            780                      39
                                          Less than 1 percent                                       730                      36
                                          Data missing                                              134                        7

                                         Source: GAO survey of hospitals, 2002.

                                         Note: Responses were weighted to provide estimates for the universe of hospitals. Percentages may
                                         not add to 100 due to rounding.




                                         Page 57                                           GAO-03-460 Emergency Department Crowding
Appendix III: Select Results of GAO Survey of
Hospitals Regarding Emergency Department
Crowding




Table 33: Indicators of Crowding, by Number of Staffed Inpatient Beds, Last Day of
Fiscal Year 2001

                                                      Number of staffed inpatient bedsa
                                                                     b                       c
    Crowding indicators                               Top 25 percent       Bottom 25 percent
    Median number of hours on
    diversion in fiscal year 2001                             196 hours                          <7 hours
    Median percentage of patients
    boarded 2 hours or more in past
    12 months                                                       66%                                8%
    Median percentage of patients
    who left before a medical
    evaluation                                                      2.0%                              1.0%

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals.
a
    Excludes long-term care, labor and delivery, and postpartum beds.
b
    Hospitals in the top 25 percent had more than 294 staffed inpatient beds.
c
    Hospitals in the bottom 25 percent had 107 or fewer staffed inpatient beds.



Table 34: Indicators of Crowding, by Number of Emergency Department Visits per
Standard Treatment Space, Fiscal Year 2001
                                                                                                  a
                                                    Visits per standard treatment space
    Crowding indicators                              Top 25 percentb        Bottom 25 percentc
    Median number of hours on
                                                                          d
    diversion in fiscal year 2001                              35 hours                        22 hoursd
    Median percentage of patients
    boarded 2 hours or more in past
                                                                          d
    12 months                                                      25%                                24%d
    Median percentage of patients
    who left before a medical
    evaluation                                                     1.6%                               1.2%

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals.
a
 Number of visits in fiscal year 2001 and number of standard treatment spaces as of the last day of
fiscal year 2001.
b
    Hospitals in the top 25 percent had more than 1,993 visits per standard treatment space.
c
    Hospitals in the bottom 25 percent had 1,426 or fewer visits per standard treatment space.
d
 No statistically significant difference between the medians for hospitals in the top and bottom
quartiles.




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Appendix III: Select Results of GAO Survey of
Hospitals Regarding Emergency Department
Crowding




Table 35: Indicators of Crowding, by Number of Emergency Department Standard
Treatment Spaces per Staffed Inpatient Hospital Bed, Last Day of Fiscal Year 2001

                                                       Standard treatment space per staffed
                                                                                a
                                                                  inpatient bed
                                                                        b                       c
    Crowding indicators                                  Top 25 percent       Bottom 25 percent
    Median number of hours on
    diversion in fiscal year 2001                                  19 hours                        97 hours
    Median percentage of patients
    boarded 2 hours or more in past
                                                                             d
    12 months                                                           22%                            37%d
    Median percentage of patients who
    left before a medical evaluation                                   1.2%d                           1.6%
                                                                                                              d




Source: GAO survey of hospitals, 2002.

Note: Number of standard treatments spaces and staffed inpatient beds as of the last day of fiscal
year 2001. Responses were weighted to provide estimates for the universe of hospitals.
a
    Excludes labor and delivery, postpartum, and long-term care beds.
b
Hospitals in the top 25 percent had more than 0.15 standard treatment spaces in the emergency
department per staffed inpatient bed.
c
Hospitals in the bottom 25 percent had less than 0.07 standard treatment spaces in the emergency
department per staffed inpatient bed.
d
    No statistically significant difference in the medians for hospitals in the top and bottom quartiles.



Table 36: Indicators of Crowding, by Emergency Department Admissions per
Staffed Inpatient Bed, Fiscal Year 2001

                                                      Emergency department admissions per
                                                                                   a
                                                             staffed inpatient bed
                                                                        b                     c
    Crowding indicators                                  Top 25 percent     Bottom 25 percent
    Median number of hours on
                                                                                 d
    diversion in fiscal year 2001                                   86 hours                     22 hoursd
    Median percentage of patients
    boarded 2 hours or more in past
    12 months                                                             46%                          19%
    Median percentage of patients who
                                                                                 d
    left before a medical evaluation                                     1.5%                         1.2%d

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals.
a
 Number of staffed inpatient beds as of the last day of fiscal year 2001. Excludes long-term care,
labor and delivery, and postpartum beds.
b
 Hospitals in the top 25 percent had more than 35 emergency department admissions per staffed
inpatient bed.
c
 Hospitals in the bottom 25 percent had less than 21 emergency department admissions per staffed
inpatient bed.
d
    No statistically significant difference in the medians for hospitals in the top and bottom quartiles.




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Appendix III: Select Results of GAO Survey of
Hospitals Regarding Emergency Department
Crowding




Table 37: Indicators of Crowding, by Hospital Ownership

                                                                           Type of ownership
                                                     Private, not-           Investor-owned                       Public
    Crowding indicators                                 for-profit                (for-profit)               (nonfederal)
    Median number of hours on
                                                                       a                           a                            a
    diversion in fiscal year 2001                          52 hours                   40 hours                       11 hours
    Median percentage of patients
    boarded 2 hours or more in
                                                                                                                                a
    past 12 months                                                40%                        22%                        23%
    Median percentage of patients
    who left before a medical
                                                                                                   a
    evaluation                                                   1.3%                      1.6%                         1.7%

Source: GAO survey of hospitals, 2002, and American Hospital Association Annual Survey Database, Fiscal Year 2000.

Note: Responses were weighted to provide estimates for the universe of hospitals.
a
 No statistically significant difference between the medians for hospitals with this type of ownership
compared with other types of ownership.



Table 38: Indicators of Crowding, by Trauma Center Status

                                                              Certified trauma                            Not a certified
    Crowding indicators                                                  center                           trauma center
    Median number of hours on
    diversion in fiscal year 2001                                           75 hours                                 32 hours
    Median percentage of patients
    boarded 2 hours or more in past
                                                                                      a                                         a
    12 months                                                                   46%                                     28%
    Median percentage of patients who
                                                                                      a                                         a
    left before a medical evaluation                                           1.5%                                     1.3%

Source: GAO survey of hospitals, 2002, and American Hospital Association Annual Survey Database, Fiscal Year 2000.

Note: Responses were weighted to provide estimates for the universe of hospitals.
a
 No statistically significant difference between the medians for hospitals that are certified trauma
centers and those that are not.




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                                                    Appendix III: Select Results of GAO Survey of
                                                    Hospitals Regarding Emergency Department
                                                    Crowding




                                                    Table 39: Indicators of Crowding, by Teaching Status

                                                                                                                                                             Not a teaching
                                                        Crowding indicators                                            Teaching hospital                            hospital
                                                        Median number of hours on diversion in
                                                        fiscal year 2001                                                            148 hours                            19 hours
                                                        Median percentage of patients boarded
                                                        2 hours or more in past 12 months                                                   59%                              20%
                                                        Median percentage of patients who left
                                                        before a medical evaluation                                                        1.7%                             1.2%

                                                    Source: GAO survey of hospitals, 2002, and American Hospital Association Annual Survey Database, Fiscal Year 2000.

                                                    Note: Responses were weighted to provide estimates for the universe of hospitals.



Table 40: Indicators of Crowding, by Select Payer Sources for Emergency Department Visits, Fiscal Year 2001

                                                                                  Medicaid and State Children’s
                                                                                   Health Insurance Program
                                             Medicare                                       (SCHIP)                                                  Self-pay
                                          Top 25      Bottom 25                         Top 25       Bottom 25                                    Top 25      Bottom 25
                                                 a
 Crowding indicators                     percent       percenta                        percent
                                                                                               b
                                                                                                       percentb                                  percentc      percent
                                                                                                                                                                       c


 Median number of hours
 on diversion in fiscal
                                                                                                      d                         d                           d                       d
 year 2001                               25 hours              76 hours                   32 hours                100 hours                     41 hours                 50 hours
 Median percentage of
 patients boarded
 2 hours or more in past
                                                d
 12 months                                  31%                      38%d                       42%d                      49%d                        38%d                  49%d
 Median percentage of
 patients who left before
 a medical evaluation                       1.1%                     1.7%                       1.8%                      1.0%                        2.3%                  1.0%

Source: GAO survey of hospitals, 2002.

                                                    Note: Responses were weighted to provide estimates for the universe of hospitals.
                                                    a
                                                     The top 25 percent of hospitals had more than 30 percent of visits covered by Medicare, while the
                                                    bottom 25 percent had 14 percent or fewer visits covered by Medicare.
                                                    b
                                                    The top 25 percent of hospitals had more than 21 percent of visits covered by Medicaid or SCHIP,
                                                    while the bottom 25 percent had 8 percent or fewer visits covered by Medicaid or SCHIP.
                                                    c
                                                    The top 25 percent had more than 20 percent of visits covered by self-pay patients, while the bottom
                                                    25 percent had 8 percent or fewer visits covered by self-pay patients.
                                                    d
                                                     No statistically significant difference between the medians for hospitals in the top and bottom
                                                    quartiles.




                                                    Page 61                                                       GAO-03-460 Emergency Department Crowding
Appendix III: Select Results of GAO Survey of
Hospitals Regarding Emergency Department
Crowding




Table 41: Hospitals Applying for Regulatory Approval to Increase Licensed Beds,
since Start of Fiscal Year 2001

    Requested approval to increase
                   a
    licensed beds?                                   Number of hospitals                 Percentage
    Yes                                                             296                          15
    No                                                            1,639                          81
    Data missing                                                      86                          4

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals and include
responses from all hospitals, regardless of whether states had certificate of need processes.
a
 According to the American Health Planning Association, 26 states and the District of Columbia
required hospitals to apply for regulatory approval to increase licensed inpatient beds in 2002, a
process known as the certificate of need process, while 24 states had no such requirement.



Table 42: Types of Beds Requested since Start of Fiscal Year 2001

    Type of bed                                 Number of hospitals                      Percentage
    Acute care (medical/surgical)                              129                               44
    Telemetry                                                   44                               15
    Intermediate                                                17                                6
    Critical care (ICU/CCU)                                     97                               33
    Pediatric                                                   11                                4
    Psychiatric                                                 36                               12
    Other                                                       97                               33

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals and include
responses from all hospitals, regardless of whether states had certificate of need processes.
Percentages are based on an estimated 296 hospitals that applied for regulatory approval to increase
licensed beds since start of fiscal year 2001. Some hospitals reported multiple types of beds.




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Appendix III: Select Results of GAO Survey of
Hospitals Regarding Emergency Department
Crowding




Table 43: Average Proportion of Emergency Visits Covered by Medicare, Medicaid
and SCHIP, and Self-Pay, Fiscal Year 2001

                                                                          Number of hospitals
 Payer source                                   Mean percentage                     reporting
 Medicare                                                    24                         1,892
 Medicaid and SCHIP                                          16                         1,884
 Self-pay                                                    15                         1,860

Source: GAO survey of hospitals, 2002.

Note: Responses were weighted to provide estimates for the universe of hospitals.




Page 63                                         GAO-03-460 Emergency Department Crowding
                  Appendix IV: GAO Contact and Staff
Appendix IV: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Kim Yamane, (206) 287-4772
GAO Contact
                  Other major contributors to this report were Diana Birkett, Jennifer
Acknowledgments   Cohen, Bruce Greenstein, Katherine Iritani, Susan Lawes, Lisa A. Lusk,
                  Behn Miller, Dae Park, Tina Schwien, and Stan Stenersen.




(290084)
                  Page 64                              GAO-03-460 Emergency Department Crowding
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