2005 National Ambulatory Survey

August , 2007
2005 National Hospital Ambulatory Medical Care Survey Jim Augustine, MD
Please take the opportunity to review the CDC statistical survey of Emergency Department operations. It is a wealth of information on Emergency Medicine in America, both the patients and the practice. It can be downloaded from www.cdc.gov/nchs. This report is from the year of 2005. The National data always trails two years behind the calendar years.
This year the report is 31 pages in length, and as always, the NHAMCS report is an easy read. It reviews patients and ED operations, and now this survey has 13 years of annual data. With this longevity, it is beginning to identify trends in the ED visits that are important for hospital and regulatory leaders to understand. This year, the author has begun the process of comparing 10 year trends on the data. The trends are (big surprise here): more ED visits, higher acuity, more medical presentations (as opposed to injury presentations), and older patients.
There is some uncertainty in the number of American EDs, but it is clear that number has decreased. The CDC uses only AHA numbers on “how many hospitals and EDs are there in the country”. It is obvious that many hospitals are not members of, nor report to, the AHA. The AHA statistics indicate there are about 3795 full service non-military EDs, and that AHA number is down about 400 hospitals in the last 10 years. But published statistics from the National Emergency Department Directory (NEDI), a project of Boston, MA-based EMNet, the Emergency Medicine Network, found more EDs. That survey found 4,862 EDs. Of that number, 1,535 saw less then 8,760 patients per year. The remaining EDs, 3,327 of them, saw an average of 32,341 patients per year. The authors of the CDC study want to help us, and report that the average ED is seeing 31% more patients in 2005 then it did 10 years ago.
It is critical that as an ED leader, you understand the data and trends in this report, and can compare them to your ED practice site. Then it is your opportunity to discuss this report with your hospital and community leaders, and provide a summary of relevant information on local trends and the effects on your ED. For example, this year’s report highlights the use of various treatment and diagnostic modalities. This should be used to emphasize your effective utilization of resources in your ED.
Media highlights of this year’s report
  • As expected and as I predicted for you, visits to the nation’s emergency departments were back on the upward trend compared to 2004, with a record high 115.3 million patients seen in 2005. The long-term volume trend is up about 2.2% per year. With the undercounting of EDs, it is undoubtedly an underestimate of the number of true ED visits in the country. Likely in 2007 we are seeing about 125 million patients in American EDs.
  • The CDC numbers indicate that there are 219 visits to American EDs every minute.
  • The report attributes the rise in ED visits to increased use by adults, especially those 65 years old and over. Among people aged 65-74, the ED visit rate was more than five times higher for those residing in a nursing home or other institution compared with those not living in an institutionalized setting.
  • The population studies that the CDC performs indicate that about 20% of the US population visits the ED within a 12 month period. Since the utilization rate of the ED is 396 visits per 1000 population, then the average patient using the ED goes there twice a year.
  • The patients presenting to the ED have very rarely been discharged from a hospital in the last 7 days. The number is 1.9% of our patients. That would indicate that our inpatient physicians have great success in discharging patients out of the hospital, and the patients not having to present back to the ED for re-evaluation.
  • The average waiting time to see a physician was 56 minutes, and on average, patients spent 3.3 hours in the ED, which includes time with the physician as well as other clinical services.
  • Injury, poisoning and the adverse effects of medical treatment accounted for over 37 percent of ED visits. Some 1.8 million visits were attributed to adverse effects of medical treatment.
  • In 2003, patients arrived at the ED by ambulance in 15.5 percent of the visits, representing over 18 million ambulance transports. More than a third of patients who arrived at the ED by ambulance were 65 years of age and over.
  • Payor mix is important to our administrators. Private insurance accounts for about 40% of ED patients, then Medicaid and CHIP (25%), Medicare (17%), and no insurance (17%). Homeless persons account for about 1 of every 250 seen in American EDs.
  • This year’s study provides a more in-depth look at diagnostic testing and treatment done on patients. About 16% of patients have an EKG performed, and about 11.5% have cardiac enzyme studies performed. These are increasing year by year.
  • Only 166, 000 patients had CPR performed, and a total of 225,000 persons were dead on arrival or died in the ED. Less then 300,000 patients were intubated.
  • About 58 percent of all EDs were located in metropolitan areas, and they represented 86 percent of the annual ED visits in this country. Board-certified emergency medicine physicians were available at 64 percent of EDs.
  • Of the patients seen in the ED, this year’s numbers indicate that 12% were admitted. This is much lower then prior years, and I believe is just a small aberration in the data. Most EDs admit about 15% of patients seen. This study indicates that the average patient admitted through the ED stays in the hospital 5.2 days.
  • This year’s report has a feature section on Patient Transfers. There are over 550,000 patient transfers for mental health or substance abuse patients, and this is the first year this number has been tabulated. On average, that is 145 transfers per ED per year.
Analysis of the National numbers
The key news was volume increase, and a record high volume in 2005. That will be a headline for politicians, policymakers, and insurance companies. That would match our prediction. The CDC 2005 data show ED volumes on the long term trendline of volume increases over 2% per year. Volumes have increased more in those EDs that are in metropolitan areas.
The second headline is the overwhelming pressures on America’s EDs resulting in diversion issues nationally. This must be matched with efforts to improve ED flow, to accommodate volumes and avoid community deaths from EMS delays. The ED leader must work with hospital leadership to improve flow of admitted patients, to avoid capacity issues in the ED..
The ED population is getting older, and getting to represent more Americans. ED visits have increased over 10 years from 369 visits per 1000 population to 396 per thousand. Those persons over age 75 had 595 visits per 1000 population. What does that mean for your planning? You need to prepare for larger numbers of patients, and you need to develop processes that are more friendly to the older population. This population group is not going to shrink! By the way, the highest visit rates per population were for those persons under age 1. There are over 900 visits per 1000 population for those 12 months of age and younger. So by the numbers, essentially all newborns are seen in an ED their first year of life. Would be a great opportunity to educate parents on proper newborn care and use of pediatricians before they go home from Labor and Delivery!
The survey numbers confirm the higher acuity trend you no doubt are feeling. More high acuity visits, more older patients, more diagnostics, and more admissions… enough? Importantly, they are trending the diagnoses. Injuries continue to shrink, and now represent 36% of visits. The biggest increase in injuries is occurring in one group: the elderly. Injury rates for those over 75 age group, injury visits have grown from 116 to 179 injuries per 1000 population. Pediatric head injuries have fallen by 75%!! Someone needs to congratulate our industry on our prevention success!
There is ongoing increase in use of diagnostic tools in the ED. 12.7% of their patients got CT, MRI, or another special imaging procedure, and additional 2.6% got ultrasound. There is a reason we use CT and other improved imaging…. It gives us the answers we need. This trend will continue.
This table should be used to complete your numbers, and compare them to the numbers from the CDC survey. This will allow you to provide an accurate report on EMP ED operations to your hospital leadership and community. Augustine1
Highlights from site reviews I have done
There is a close relationship of ALOS and LBTC. For EDs seeing less then 55 patients per day, it appears that ALOS needs to stay below 100 minutes, or patients begin to walk away. Between 55 and 110 patients per day, the ALOS needs to stay below 120 minutes or patients walk away. A great ED I follow closely …. They produce an ALOS of 78 minutes and almost all patients stay. By their numbers, only 1 in 300 patients leave before treatment is complete. That is outstanding! EDs seeing over 110 patients per day have longer ALOS, but those that stay below 150 minutes see fewer walkaways. Not all EDs can produce numbers on ALOS, but those that can usually get good results from sharing them with staff. Walkaway rates from EDs were 1.2% is 1992, and now has increased to 3%. You need to know how this compares to your facility number.
The Physician acuity codes for your ED should be available. Over time, they tell the story of increasing acuity of the patients seen. An annual report should summarize high acuity vs low acuity codes. Other site-specific numbers helpful in planning your ED operation:
  • Zip Code of origin
  • Male vs Female (Females usually outnumber males in the ED)
  • Age mix of patients seen (useful overall showing a trend to older patients)
  • Most common ICD-9 and CPT codes (useful site-specific and overall. Shows progressively fewer procedures, more presentations of medical illnesses, more dyspnea, chest and abdominal pain)
This year’s CDC analysis highlights Transfer percentages, and reasons for transfer. Most EDs have tight EMTALA procedures. EMS arrivals and admission percentage of EMS arrivals is useful at each site for planning purposes. Efforts to improve service to the ambulance companies, particularly those delivering 911 system patients, is usually rewarded with better care and more patients. This is healthy for the patients, the ED and the hospital. The use of EKG, imaging, and respiratory services is a relatively new trend to follow. It gives the ED a much clearer picture of what services it must provide.
Each of these services are increasing in their usage.
The admission percentage from the ED keeps creeping higher, despite more stringent criteria for admission. I note higher admission rates at the larger hospitals seeing adult patients.

You must know the percent of overall hospital admissions presenting thru the ED. Almost all the EDs I am familiar with have more then 50% of hospital admissions coming through the ED, and the average number is 63%. This clearly demonstrates that the ED is the “Front Door to the Hospital”.
Conclusion

It is exciting to review these Emergency Department operational numbers. It is a great opportunity to characterize the Emergency Department practice in a very positive fashion. The hospital’s CEO and Board of Directors should be updated on the statistics. Please continue the efforts of your Emergency Department to collect, report, and understand the operations of your ED, while drawing some insight from National figures. Summary Talking Points
  • There is a long term trend that American EDs are seeing about 2.2% more patients per year.
  • The average American ED is seeing 31% more patients then it did 10 years ago, and is seeing more then 32,000 patients per year.
  • More patients arrive with medical illnesses, rather then injuries.
  • More patients are elderly, and arrive by EMS.
  • The largest group of patients being seen in the ED have private insurance.
  • The highest utilization of Emergency Services occur among nursing home residents. The next highest utilization is by infants under age 1.
  • Homeless and uninsured persons use the ED about as frequently, on average, as a Medicare patient.
  • Around 40% of patients over the age of 18 present to the ED with a blood pressure above 140/90
  • There is a great success story in how effectively we discharge patients from the inpatient environment. Less then 2% of emergency department patients were discharged from a hospital in the last week.

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