The 2015 Emergency Department Benchmarking Alliance (EDBA) Performance Measures survey includes almost 1,200 emergency departments that served about 50 million patients, plus 57 additional freestanding emergency departments or urgent care centers.

The National Hospital Ambulatory Medical Care Survey (NHAMCS) from the Centers for Disease Control and Prevention (CDC) gives a statistical estimate of emergency department patients, treatment, and disposition based on federal demographic data and a statistical sampling of visits to American emergency departments. However, there has been no data release since December 2014, when the 2011 data tables were published. Emergency medicine leaders and ACEP have provided support for the CDC to publish this important release of data on an ongoing basis and have written to encourage them to publish data from years 2012 onward.

If we create an estimate based on the last published CDC numbers for 2011 of 136.3 million visits and include the historical average growth in emergency department visits since 1992 of about 2.5 percent over the subsequent five years, the American emergency department volumes seen in 2016 are likely going to hit about 150 million visits.

EDBA members reported that their volume increased as acuity remained stable. The ED patient volume at the same sites reporting in 2014 and 2015 increased by 4.3 percent—many departments had a higher increase in volume than that figure. Acuity mix, measured by physician level of service and by the percentage of patients who were admitted to the hospital from the emergency department, remained stable from 2014 to 2015.

About 75 percent of departments with an annual visit volume of more than 40,000 reported a “fast track” for patient care, and about 35 percent had a clinical decision unit or observation unit.

Children Versus Seniors

For 2015, there was a shrinking percentage of children treated in emergency departments, and therefore, the volume growth in American departments was based on increasing numbers of senior patients. This should be verified when the CDC publishes updated NHAMCS numbers, which will show an increasing level of Medicare patients.

There also was a growing number of trauma centers, particularly at the categories of Level II and Level III. Many of these new trauma centers serve injury populations that include large numbers of elderly patients. These service improvements are occurring in all regions of the country, not just the traditional Sun Belt locations.

Structure and Processing

Emergency departments have changed structure as they’ve grown in volume and complexity. Bed utilization was about 1,500 visits per patient care space. This was much lower in departments serving adult patient populations, at about 1,334 visits per care space. For departments serving pediatric patient populations, the figure was 1,887 visits per care space.

There also was an increased use of electronic information systems. Computerized physician order entry (CPOE) is present in more than 90 percent of emergency departments. That’s high enough that CPOE is now considered ubiquitous technology, and the EDBA survey question related to it will be removed from future data surveys.

Despite the increase in volume, the survey found that patient processing in emergency departments has improved. The door-to-doctor time was about 27 minutes on average, and the overall length of stay for all emergency patients was less than three hours. About 75 percent of departments with an annual visit volume of more than 40,000 reported a “fast track” for patient care, and about 35 percent had a clinical decision unit or observation unit. The percentage of patients who left the emergency department prior to the completion of treatment, however, increased to 2.4 percent.

Transfer/Inpatient Boarding

Patients who require transfer and inpatient boarding are a significant challenge to emergency department operations. The inpatient units were the site of disposition of emergency patients in about 16 percent of visits, and about 1.4 percent of patients were transferred to another hospital, typically for admission. (The emergency department was the predominant front door for hospital admissions, with about 67 percent of hospital inpatients being processed through it.)

There was a stable volume of patient transfers: 1.4 percent of all patients, or almost 2 million a year. According to the 2011 CDC report, about one-third of patient transfers from emergency departments—or about 700,000 patients per year—were for mental health treatment.

The boarding time interval—the time from decision to admit until the patient physically leaves the emergency department—has stabilized for patients being placed in an inpatient unit of the hospital. The average boarding time in American departments was 111 minutes, but this time interval was very cohort-dependent. Emergency department inpatient boarding accounted for about 37 percent of the time an admitted patient spent in emergency. Boarding time ranged from about 170 minutes in departments with a patient volume of more than 80,000 to 67 minutes for departments seeing fewer than 20,000 patients. Emergency medicine leaders appear to have not been able to make much headway in reducing boarding time.

Emergency Medical Services

EMS continues to be an important source of volume for emergency departments, particularly for sicker patients. About 17 percent of patients arrived by EMS, and about 38 percent of those patients were admitted.

Diagnostic Testing

Diagnostic testing use is evolving in the emergency department. The survey found increased use of MRI scans and ultrasounds. MRI scans were performed a little more than 1 time per 100 patients seen, and ultrasound use was about 5.7 procedures per 100 patients seen. For the first time in the last 12 years, there was a leveling off of the utilization of ECGs, which were performed about 26 times per 100 patients seen. There was a continued downward drift in the use of CT scans, with a utilization rate of about 21 procedures per 100 patients.

Emergency physicians are responsible for high-quality and safe service in around 150 million patient encounters in the United States per year. Trends indicated in the NHAMCS database and in EDBA data surveys will continue to provide guidance regarding the value of emergency care in serving the needs of sicker, older, and more challenging patients.