AHA survey highlights ED overcrowding issues

Shortage of critical care beds cited

Half of the nation's emergency departments (EDs) are at or over capacity, and a majority of hospitals have reported time on ambulance diversion, according to the American Hospital Association's 2006 Survey of Hospital Leaders.

The most common reason given for diversion was not ED overcrowding, per se, although that was the second-most frequently cited issue, says Caroline Steinberg, vice president for trends analysis in AHA's Washington, DC, office, but rather the lack of staffed critical care beds, which leads to patients having to "board" in the ED until a bed is available. (See chart, below.)

Urban (68%) and teaching hospitals (75%) reported the greatest amount of time either at or over capacity in their EDs. (See chart, below.)

The survey was sent to about 4,900 hospital CEOs in late February via fax and e-mail, and data was collected through March.

Even when the demand for inpatient care was declining due to the pressures of managed care and the effects of hospital mergers, ED demand has never stopped growing, Steinberg notes, even as many hospitals and EDs have closed.

Those hospital closings have contributed to capacity constraints that are also increasing inpatient demand, a trend that has been somewhat unexpected, she adds. "There was a lot of downsizing and consolidation in the early '90s, and the thought was that we would continue to see declines in patient admissions."

Also contributing to the ED shortage is a new trend toward limited-service hospitals, Steinberg notes. "These are physician investor-owned facilities without EDs."

Outpatient visits, meanwhile, have been on an almost uninterrupted upward trajectory since 1990.

One of the most notable trends in outpatient care, Steinberg says, is the "massive migration of care outside the hospital, as increasing numbers of complex surgeries are moving to freestanding ambulatory centers and to physician offices.

"One of the concerns there is that those facilities tend to be less regulated than hospital outpatient departments," she notes.

The rate of increase in hospitals becoming part of health systems has gone up in the last few years, Steinberg says, but is less than in the mid-'90s.

"Managed care pushed a lot of integration and a reduction in capacity," she adds, "and there was the capital crunch with the Balanced Budget Act. Hospitals were suffering financially and one way to access capital is to merge."

However, she adds, "the pressure from managed care is less now and there is a limit to how many mergers you can have."